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Religion and Health Project Evaluation
Data Analysis and Final Report
Anims at the Kuenga Rabten Anim Dratshang
Dratshang Lhentshog Health Division UNICEF
(Prepared by: MarionYoung - July 1999)
824BT—16994 LIBRARY IRC P0 Box 93190, 2509 AD THE HAGUE Tel.: +31 70 30 689 80 Fax: +31 703589964 BARCODE: 16559 RHP Evaluation Report - Inlroductioii
Religion and Health Project Evaluation
Data Analysis and Final Report
Anims at the Kuenga Rabten Anim Dratshang
Dratshang Lhentshog Health Division UNICEF
(Prçpared by: Marion Young - July 1999)
I. 1 RHP Report 1 Introduction RHP Evaluation Report - Introduction
RI-IP Report I Introduction RHP Evaluation Report - Introduction
Menchey Rimdu Medicine and Puja
Some years ago a young Bhutanese boy fell sick. He couldn’t walk, he couldn’t feel anything in his hands and feet and he didn’t want to eat anything. His mother called the health worker who came from the BHU four hours away to see the boy. The health worker left ~onie medicine for the boy to take but every time he was given the medicine it made him vomit. His mother called the local religious practitioner who told the boy’.s mother that an evil spirit lived in the tree outside the house. They must cut down the tree and plant another tree in its place. Only then would the boy be ‘able to take the medicine. This was done the tree was cut down, another tree was planted and the boy was able to take the medicine. Happily for the whole family. the boy recovered.
The boy is now a monk and has recently attended Religion and Health Project training. He and his family believe that both puja and medicine work together.
A personal story told by a rponk in Bhutan June 1999
RHP Report I Introduction RHP Evaluation Report - Introduction Table of Contents
INTRODUCTION 7
RUP PROJECT OBJECTIVES 8
RHP EVALUATION OBJECTIVES 9
EVALUATION REPORT AND EVALUATION ANALYSIS 9
BACKGROUND TO THE RHP PROJECT 10
EVALUATION METHODOLOGY 12 EVAIJJATION TooLs 12 EvAI.tJArloN PROCESS 13 EVALUATION LIMITATIONS 20
KEY QUESTIONS 23
KEY QUESTION a I. - ROLE OF RELiGIOUS COMMUNITIES IN PROMOTING HEAL TH 25
Is f/ic health pronlotion role of ~ religious coiiiiiiun hi (ordained monks) acid/or coininunitv—based reli~ç’iouspractitioners understood by //ieniselves (acid hi’ the coinnuueinlj’ and by health workers)? 25 CONCLUSIONS 26
KEY QUESTION a2. - ROLE OF RELIGIOUS COMMuNITIES IN PROMOTING HEALTH 27 Hon successful have the religious community cind/or conumuni y—hasedreligious practitioners been in their role as heal//i promoters (v/en’s of religious communities themselves, co,nmunhtv nieinbers and health ti’orkers to he asked,I? 27 CONCI,IJSIONS 28
KEY QUESTION a3. - ROLE OF RELIGIOUS COMMUNITIES IN PROMOTING HEALTH 29
DC) ihe religious comifluflity cind/or coniniuniti’—hcised religious prcuciitioner,s kel 1/ia! 1/icy can contribute i/lore in pro/noting health? lives. u/cat more and lion’? 29 CONClUSIONS 30
KEY QUESTION a4. - ROLE OF RELIGIOUS COMMUNiTIES IN PROMOTING HE/IL TII 31
Do coinnn,nm’-hased religious practitioners (such as tsips. pawos, pamos, gomchens, /akris) view the role heiny promoted by the RI-/P as ci i/flea! to their livelihood? (above cited people are usually a~iproachec/in times of ill health to pertorni rituals/pu/as and get paid in cash or kind for their services) 31 CON:I.lJsIoNs I KEY QUESTION bI. BEHAVIOURAL CHANGES IN THE RELIGIOUS COMMUNITY 32
/1re thc’re c/ianges in the heal//i seeking acid hi‘glene practices of the religious comninlinity and/or coinnuinit v—basedreligious pracii/loners (i/Icr RI—/P irai/flhig workshops.’ 32 C0NI.vsIoNs 33
KEY QUESTION b2. - BEHAVIOURAL CHANGES IN THE RELIGIOUS COMML/NIT}’ 34
flout’ /iave 1/ic iniproveci uc’aicr/sanita/ion/acilities been used aiid niaiilainecl.’ 34 CONClUSIONS 3S
KEY QUESTION b3. - BE/IA VIOURAL CHANGES IN THE RELIGIOUS COMMUNITY 36
I—/ate I/ic’ religious conc/lulnitys a,!ituck’s toii’arc/s sanitation and hygiene changed ni/li the introduction of i/n/iroVecl n’atec~sa;ii/ationfacilities.’ 36 CONCI,IJSIONS 36
KEY QUESTION b4. - BEHA VIOURAL ChANGES IN TIlE RELiGIOUS COMMUIVIT 37
RI-IP Report I Introduction 4 RHP Evaluation Report - Introduction
Do the religious conimnunity cucici/or comm unity—basedreligious practitioners provide advice on health care when approached fbr religious services in the event offamily illness? 37 CONCLUSIONS 37
KEY QUESTION ci. - BEHAVIOURAL CHANGES IN THE COMMUNITY 38 Do c’omnmnuni/ members receive health advice from the religious communitV and/or community-based religious practitioners when approached/or religious services in the event offancily illness? 38 CONCLUSIONS 38
KEY QUESTION c2. - BEHA VIOURAL CHANGES IN THE COMMUNITY 40 Has the religious conunu unity and/or theconinu unity—based religious practitioners influenced the health seeking amid hygiene practices of the community? 40 CONCLUSIONS 40
KEY QUESTION c3. - BEHA VIOURAL CHANGES IN THE COMMUNITY 42 Are there any ac/c/edac/vantages oft/ic religious’ conumnunity acid/or conununity—hased religious prcuc’titionem~s’pro/noting /cecm It/i? 42 CONCIIJSIONS 42
KEY QUESTION c4. - BEHA VIOURAL CHANGES IN THE COMMUNITY 43 Are the,’e c/ianges in the heal/li seeking and hygiene practices o/the religious conimunity and/or conunuinity—liased religious practitioners after RHP training ii’orkshops? 43 CONCI.IJSIONS 44 KEY QUESTIONd1.-HEALTH WORKERS’ VIEWS 45 Rate 1/ic effectiveness (?f the religious conununity and conumziniiv—based religious practitioners as promoters 0/health nuessages 45 CONClUSIONS 45
KEY QUESTION d2. - hEALTH WORKERS’ VIEWS 46
Do /ueciltli 1 ‘orkers view 1/ic religious conunu,ui/I’ and coinmnumnty—basec/ religious practitioners as competitors or conuplenmentcirv:’ 47 Conclusions 47
KEY QUESTION d3. - HEALTH WORKERS’ VIEWS 48
I-las there been an increased number of pcmtientsfi’onu f/ic conunu/uty referred by the religious’ community cinch/or community—based religious practitioners f/illon’ing RI—/P n’orks/iops? 48 CoNcLusIoNs 48
KEY QUESTION el/ e2. - EFFECTIVENESS OF TRAINING WORKSHOPS 49
JVluit knoi’ledge /uci.s’ /een retained by religious p~~on.s’who attended RI-/P training ui’orksliops? 49 R/icut is the know/cc/ge of religious persons lu’/io have not heemi trained? 49 CONCUISIONS 50
KEY QUESTION e3. - EFFECT! VENESS OF TRAINING WORKSHOPS 52 I Chat acldutionc,l areas of lieu/tb n’oulcl the reli~giou.sconnmmunitv d,nd/./or comnmnumnity—basec/religious /1/ductitioners like to Iccurn cibouit in the training workshop to enhance their role as health promnoter.s’? 52 CONClUSIONS 53
KEY QUESTION e4. - EFFECTIVENESS OF TRAiNING WORKSHOPS 54 How cciii tmaining workshops befuirther immupm-ovecl.’ 54 CONCLUSIONS 54
KEY ISSUE - EFFECTIVENESS OF PROJECT MANAGEMENT 55 Hon ccnu RH!’ pro/ect nucunagecuuent be further improved? 55 CoN~.ItJsIoNs 55
KEY ISSUE — STD/AIDS 57 Issues relating to ~S’TD//I/DSknowledge among religious prcic’titioners 57 CONCI.USIONS 58
RHP Report I Introduction RHP Evaluation Report - Introduction
MAIN CONCLUSIONS 59
COMPARATIVE ADVANTAGE OF RELIGIoUs PRAC’FITIONERS AS HEALI’H PROMOTERS 62 RECOMMENDATIONS 62 FUTURE STRATEGIES AND ACTIVITIES: SUGGESTIONS FOR PROJECT IMPROVEMENT 63
STRATEGY I: PROJECT MANAGEMENF ANI) PAR’I’NERSIILP 63 POSI’-EVALUATION REVIEW OFTI-IE RI-IP PROJECT 13Y SI’AKEIIOI.DERS 63 ACTIVItY I: REVIEW PROJECI’ OBJEC’I’IVES 63 ACTIVITY 2: REVIEW ROLES AND RESPONSIIIII..ITIFS 64 ACTIVITY 3: DEFINE PRIORITY TARGET GROUPS 65 AcTIVITY 4: DRAW ISP A PLAN OF ACTION 65 ACTIVITY 5: REVIEW OPPORTUNITIES FOR CiREATER DIX’EN’I’RAI..ISAFION 65 ACTIVIlY 6: FACILITATE A NFL-WORK BETWEEN COMMUNICATORS OF H+I-I MESSAGES 66
STRA’IEGY 2. MoNITORING ANI) EVALUATION 67 INTRODUCE A MONI’I’ORING ANI) EVAluATION PROCEss 67 ACTIVITY 7: BASEE.LNE DATA COLLECILON 67 ACTIVITY 8: Tool_s FOR ON—GOING MONIIORINCi OF SoFTWARE ANI) HARD WARE.....,...... 67 ActIvITY 9: USE OF WORKSF 101’ REPORTS 68 ACL’IvL’I’Y 10: ROLES AND RESPONSIBIlITIES FOR MONIlORING & EVALUATION 68 ACtIVItY II: PLANNING FOR EVALUATION 68
SLRA’IEGY 3. TRAINING 71
RFVll~\vDIE PRESENT TRAINING PROGRAMMES ANI) MODIFY AS NECESSARY ...,...... ,.....,,.....,.,.,..,.,,.,.,,.,,.,,. 7I
AcIIvvI’Y 2: IDFNTIFICATION 01 AR(iCI GROUPS ANI) PRIORITIES .,,,.,,..,,,,.,.,.,,,,,,.,,.,,,.,.,,,,.,,..,,.,,,,,.,.,,,.,,,., 72 ACTIVFFY 13: NEEDs ANAlYsIS 72 ACI1VIIY 14: WORKSIIOP PI_ANNING 72
ACtIVITY IS: REVLE~vRHP TRAINING - ALTERNATIVE MODELS 73 SUMMARY OF FUTURE STRATEGIES AND GUIDELINE OF ACTIVITIES 74
PR0JI.cr MANAGEMENI AND PAR IN! RSI LIP 74 MONItORING AND EVALUATION 74 TRAINING 74
EXAMPI.! I: SIAKEIIOI,DER l’ARrIcIpAFION ANAlYSIS MAtRIX — .WII() I)OIS WIIAT’ 75 ExAML’IE 2: SWOC ANALYSIS (SIRENOTI IS, WEAKNESSES, OPI’oitIIJNlIIFs. CONSTRAINTS)...... ,.....,...... 76
EXAMI’IE 3: AC’I’IVIrII~sANI) ACTION — WIIO/WIIEN 77 EXAMPLE 4: M0NIIORING FItAM[;woltk FOR RH!’ WORKSIIOPS 78 (;LOSSARY 79
RI-IP Report 1 Introduction 6 RHP Evaluation Report - Introduction
Introduction
The Religion and Health Project was initiated in 1992 forming a partnership between the Central Monastic Body. Dratsang Lhentsog and Health Division with financial support from UNICEF. The project has two basic components: a) Training of religious communities in basic health information in order for them to become good role models and effective health promoters b) Improvement of water sanitation and kitchen facilities of monastic institutions.
In preparation for the joint RGoB and UNICEF mid-term review of the current country programme (1997-2001), an evaluation of the Religion and Health Project was undertaken from April to July 1999.
Development of an evaluation protocol was contracted to Ms Caroline Marrs who presented the evaluation tools and methodology at a pre-evaluation workshop attended by all project stakeholders in May 1 999.
Data collection, analysis and report preparation was contracted to Ms Marion Young. A translator, Sonam Dhendup. accompanied Ms Marion Young throughout the field work data collection phase. Piloting of the evaluation tools was conducted jointly with the Ms Marrs and Ms Young. The draft report was presented to the stakeholder group in .luly 1 999. before finalisation and submission to UNICEF, Bhutan.
‘Throughout the fieldwork every assistance was offered to the evaluation team from the Dratsang and health services at each site visited. This alone was enough to convince anyone of the high value placed on the Religion and Health Project. UNICEF staff assisted with oftice preparation and support. Dratsang Lhentsog enabled the work to proceed smoothly by accompanying the evaluation team during the pilot and first field visits to assist with technicalities of translation and protocol; Dratsang Lhentsog also ensured that all permits were obtained and officials informed in advance of the evaluation teams’ visit to each site.
The evaluation work was both interesting and enlightening. I trust the Evaluation Report and Evaluation Analy~isoffers some clear insights into the progress of the Religion and Health Project to date and some uselul guidelines for the future drawn from the wealth of experience olthose who participated so willingly in the evaluation.
Tashi Delek
7 RHP Report I Introduction RHP Evaluation Report - Introduction
RHP Project Objectives
UNICEF’s Master Plan of Operations for 1997-2002 identifies the following general and specific objectives for the Religion and Health Project (RHP):
General Objective: To improve the quality of life of the Bhutanese people by harmonising religious faith and practices with information on modern health care, particularly for child survival.
Specific Objectives: 1) To promote health and nutrition education to parents through informed monks and community-based religious practitioners.
2) To increase the knowledge and skills of community-level practitioners to provide adequate advice on modern health and child care.
3) To increase capacity and strengthen motivation of the monks and monastic teachers in incorporating modern health-care in their teachings and life-style.
4) To improve physical facilities at the monasteries, enabling the monks to practice improved sanitation and hygiene, and promoting personal hygiene practices.
5) To broaden the curriculum of the monastic education system to include preventive and promotive health information.
At the RHP Review Meeting of December 1st, 1998, the point was made that Specific Objectives 4) and 5) might be better considered as strategies rather than as objectives. Instead, it was agreed that these two objectives would be termed “Immediate Objectives” and that the project’s objectives be reformulated along the following lines:
Long- Terna Objective.’ To improve the health of the people in general and women and children in particular to attain the goal of “Health for All by year 2000”.
Immediate Ob/ectives: I) To improve physical facilities at monasteries enabling monks to practice improved sanitation and personal hygiene.
2) To increase the knowledge and skills of the community-based religious persons to provide adequate advice on health and child-care.
3) To broaden the curriculum of the monastic education system to include health and hygiene information.
These are the objectives that have been retained for the present evaluation.
RI-IP Report I Introduction 8 RHP Evaluation Report - Introduction
RHP Evaluation Objectives
Following the terms of reference supplied by UNICEF, the general objectives of the present evaluation are to:
1. Evaluate how well the project’s strategies have helped to achieve the programme’s overall goals; 2. Develop future strategies by identifying areas of the project which could be improved, particularly in the areas of monitoring, training and project management; and 3. Develop a guideline for future activities in the areas of monitoring, evaluation, training, project management and partner coordination.
Evaluation Report and Evaluation Analysis
The report will be presented in two sections:
Evaluation Report. and Evaluation Analysis
The Evaluation Analysis is a complete documentation of all responses to open and closed format questions for all the tools used. It could be considered as an Appendix for people to refer to if they require some further detail not presented in the evaluation report.
The Evaluation Report draws information from the Evaluation Analysis for each tool to provide INDICATORS and CONCLUSIONS to each KEY Q.UESTION.
Evaluation Objective 1 is covered in Key Questions and Main Conclusions Evaluation Objective 2 and Evaluation Objective 3 are covered in Future Strategies and Guidelines for Future Activities
9 RHP Report I Introduction RHP Evaluation Report - Introduction
Background to the RHP Project
In 1989, the Health DiviSion and the Dratshang Lhentshog conducted a National Workshop on Health and Religion. This workshop represented the formal recognition of the health promotion potential of the religious leaders in the country and led to the development of a government project, “Health and Religion”, supported by UNICEF.
Project activities started in 1990. Activities implemented since the inception of the project include:
Training: 1,100 religious practitioners in over 13 dzongkhags trained in basic health knowledge and practice, with decentralisation of training to the gewog-level instituted since 1995;
Water/Sanitation: Water supply and sanitation facilities upgraded in 1 5 monastic institutions;
Curriculum Development: Dzongkha versions of’Facts for Life and Health is in Our Hands have been made available to religious institutions.
In order to put the project in perspective, some background information on the religious communities in Bhutan is briefly presented.
There are approximately 3,000 Buddhist monasteries in Bhutan, of which:
- 20 Rabdeys (with anywhere from 100 to 300 monks);
- 19 Monastic schools;
- l 3 Shedras (Buddhist Colleges);
- 1 5 Druhdras (Meditation Centres);
- several Nunneries; and
- numerous Lhakhangs (smaller monasteries) and Gomde s (temples).
A Rabdey is the most senior institution in each dzongkhag. Each Rabdey is headed by a Ne/en (Abbot) and run by four senior Lopen.s’, four Choetrim Zhis (religious administrators). four junior Lopens and a Ditngchen (Secretary).
There are thousands of Buddhist religious personnel in the country, of which:
- 3,500 state supported monks;
- 4,000 more receiving education/training in state-supported institutions;
- 3.000 on private patronage (including most nuns); and
- about 1 5,000 gomchen (lay monks).
In addition to these Buddhist practitioners. there exist numerous other religious practitioners. including some from pre—Buddhist and Hindu traditions. such as: ts’ips, pawos, pa/nov. pundits’ and jakris.
RI-IP Report I Introduction I0 CORRECTIONS
• Training: 2,378 religious practitioners in 19 Dzongkhags trained in basic health knowledge and practice, with decentralization of training to the geog-level instituted since 1995;
• Water/Sanitation: Water supply and sanitation facilities upgraded in 35 monastic institutions;
• Punakha Rabdey to be read as Pung.-Thim Dratshang RHP Evaluation Report - Introduction
Financial input into the Religion and Health Project for 1992 to 1998
Activities 1992 1993 1994 1995 1996 1997 1998 Total
Study tour for key people in Dratshang 21,000,00 $ 21,000.00
Training of two project staff in Management - 3,650.00 3,700.00 $ 7,350.00
Consultant to support the R&H project 2,000.00 5,116,00 350,00 6,257,00 $ 13,723.00
Supply of reference book Health is in our Hands 2,163.00 7,029.00 $ 9,192.00
Projectestablishmentsupport 1,270.00 4,035.00 1,269.00 5,481.00 50.00 $ 12,105.00
Training workshop for monks and community
based religious persons 1,934.00 16,138.00 17,616.00 9,08400 28,773.00 3,203.94 8,904.54 $ 85,653.48
Monitoring 1,200.00 $ 1,200.00
Consultation workshop for Dratshang Dungchen,
District Engineers, DMOs and DHSOs 3,330.00 , $ 3,330.00
Training of Trainers for Dungchens and Health
Workers 562.00 $ 562.00
Wafer and Sanitation and kitchen improvement 8,910.00 18,149.00 44,012.00 42,322.00 3,380.00 48,195.00 28,470.00 $ 193,438.00
Totli: $10,844.00 $62,370.00 $76,584.00 $58,375.00 $43,950.00 $ 51,798.94 $ 43,631.54 $ 347,553.48
11 RHP Report I Introduction RHP Evaluation Report - Introduction
Evaluation Methodology
Evaluation Tools
The evaluation tools and methodology, presented in a separate package, were designed by Ms Caroline Marrs and piloted-by Ms Marrs and the Evaluator prior to the start of the fieldwork,
It had been the intention of UNICEF Bhutan Office to employ a local Bhutanese evaluator in keeping with the original concept paper proposal published by Dr Jigmi Singay (Dec.1990). Unfortunately the recruitment of a national evaluator was not possible. Consequently Ms Marion Young was contracted to take on the field work, analysis and report presentation.
As the fieldwork required local language proficiency Sonam Dhendup, a class 12 student, was selected as translator to accompany the evaluator throughout the fieldwork. The evaluator and translator attended a pre-evaluation presentation of the Evaluation Tools given by Ms Marrs. RHP staff briefed the translator on specific health and hygiene terminology used in the evaluation tools, for example difficulties of translating dehydration and malnuli’ition into Dzongkha.
The evaluation tools were designed within the following structure:
• Nine tools were developed to represent the range of stakeholders: Tool I Water/Sanitation Observation Checklist [open/closed I Tool 2 Health Knowledee Test [closedi Tool 3 Institution—based Religious Community Questionnaire [open/closed] Tool 4 Institution—based Religious Community in-depth Interview [open] Tool 5 Health Workers Questionnaire [open/closedi Tool 6 Community Questionnaire [open/closed I Tool 7 Community-based Religious Practitioners Questionnaire [open/closedi Tool $ Community-based Religious Practitioners in-depth Interview [open lool 9 I3rief Interview with DHSO [open]
• Four packages were produced to represent the range of Rl-lP inputs:
Package I: Evaluation Tools for Institution-based Intervention Sites (1-lardware and Software) To assess effects in monastic institutions where the RHP has intervened both in water/sanitation upgrades (hardware) and training (software).
Package 2: Evaluation Tools for Institution-based Intervention Sites (Hardware—only) To assess effects in monastic institutions where the RHP has intervened solely in water/sanitation upgrades (hardware).
Package 3: Evaluation Tools for Control Sites (No Proiect Intervention) To assess the health practices and roles of monastic institutions where there has been no RJ-~P intervention to date.
Package 4: Evaluation Tools for Gewog-based Intervention Sites (Software-only)
RI-IP Report I Introduction 12 RHP Evaluation Report - Introduction
• The country was divided into four geographical zones. Sites were selected to represent
each zone: -
Zone I: Chukha, Samtse, Haa, Paro and Thimphu. Zone 2: Gasa, Wangdue Phodrang, Punakha, Dagana, Tsirang. Zone 3: Trongsa, Bumthang, Lhuntse, Sarpang, Zhemgang. Zone 4: Mongar, Trashiyangtse, Trashigang, Pemagatshel, Samdrup Jongkhar.
The evaluator felt that there were some limitations to the evaluation design and planned use of the evaluation tools, caused in part by having to contract the design consultant, an external evaluator and a translator. The limitations of the tools and methodology are discussed further in the following two sections, evaluation process and evaluation limitations.
Evaluation Process
Pilot: At the pre-evaluation workshop it was agree that the evaluation tools be piloted. For this purpose the methodology design consultant, the evaluator, the translator and Lopen Tashi Geley from Dratsang Lhentsog RHP Office visited two sites, Dalida Shedra and Thinleygang BHU over a two-day period. All the tools were trialed and feedback was received from participants as well as from the evaluation team. This exercise was invaluable for the modification of some questions and also for the translator and the RHP gelong to discuss the fine-tuning of the interview technique.
Workplan: Also at the pre-evaluation workshop the committee agreed on the minimum revised workplan to be used for fieldwork. The selected workplan covered 10 sites distributed evenly across zones and packages. The workplan had to be substantially modified at the outset of the field work phase because: (i) not enough time had been allowed for travel to two sites with a minimum one day walk; (ii) the required permits to visit two districts were not approved by the Home Ministry for security reasons. Six out of 10 sites and 2 out of 5 districts in the original plan had to be revised one day before the scheduled start of the fieldwork, The issue of permits to visit restricted locations may not have arisen had the evaluator been a national person.
The revised original field workplan with which the evaluation team started the fieldwork included 11 sites covering all four zones and all four packages. The Original Field WorkPlan [p.151 allowed two days at each site in addition to travelling time. Once the evaluator and translator started using the evaluation tools in situ, it became clear that: (i) two days was more than sufficient time to complete the full package of interviews at each site; (ii) a fifth package requirement was identified for sites in which there had been only a
software input and no hardware — this was categorised as Package 1 a and the tools designed for use with Package I were used; and (iii) Package Ia and 3 and Zones 2,3 and 4 were less well represented.
A further revision to the field workplan was proposed to UNICEF. Dratsang Lhentsog and Flealth [)ivision by the evaluator and was approved. This added 9 sites to the original 11 sites giving a total of 20 sites across 8 districts with a better distribution of zone and package coverage. The final revised field workplan and details of sites visited by zone and package used is presented on pages 16 and 17.
13 RHP Report I Introduction RHP Evaluation Report - Introduction
Punakha Rabdey Bumthang Rabdey Bumthang Kurjey Lhakaiig
Mongar Dremetsi Shedra Mongar Ngatshang Shedra
Paro Keela Gompa
Mongar Kadam Gompa
Mongar Rabdey
Chuka Chapcha Community Chuka Rabdey
Tsirang Rabdey ongsa Rabdey Tsirang Tsokhana Community Tongsa Kunga Rabten Nunnery Tsirang Shemjong Community Tongsa Langtel Comnuinity Tsirang Chanauti Comim.inity Tongsa Nyimshong Community
RHP Report I Introduction 14 RHP Evaluation Report - Introduction
Original RHP Evaluation Field Workplan - Max’ / June 1999
Marion Young - Evaluator& Sonam Dhendup - Translator
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
May 24 25 26 27 28 29
Thimphu Tango Thimphu — Tango Paro - Rabdey Paro - Rabdey Paro - Keela Gonipa
30 31 Junel 2 3 4 5
Paro - Keela Gompa Chuka — Rabdev Chuka --. Rabdey SilverJubilee — Free Silver Jubilee - Free Chuka - Chapcha Chuka - Chapchia Community Community
6 7 8 9 JO II 12
Free - Analysis liiimphu to Tongsa Tongsa Rabdey Tongsa Rabdey Tongsa to Nyinishong Nvimshong Nyimshong Comm unitv Community
13 4 15 16 17 18 19
Nvimshong to Free— Analysis Tongsa to Mongar Mongar— Rabdey Mongar - Rabdev Mongar - Ngaishang Mongar - Ngatshang Tongsa Shedra Shedra
20 21 22 23 24 25 26
Free - Analysis Mongar to Tongsa Tongsa to Tsirang Tsirang Rabdev Tsirang - Rabdey Tsirang - Tsirang - Community Community
27 28 29 30 31
Tsirang to Thimphu Free — Analysis Free Anal~sis
I5 RHP Report I Introduction RHP Evaluation Report - Introduction
Final revised RHP Evaluation Field Workplan - May / June 1999 Marion Young - Evaluator & Sonani Dhendup - Translator
Sunday Monday Tuesday Wednesday ihursdav Friday Saturda\ May 24 FW 25 FW 26 F~V 27 FW 28 FW 29
Thimphu — Tango Thimphu — Tango Paro - Rabdey Paro - Rabdey Paro - Keela Gompa
30 31 Junel 2 3 4 5
Paro - KeelaGompa Chuka— Rabdev Chuka— Rabdev Silver Jubilee - Free Silver Jubilee - Free Chuka - Chapcha Free - Analysis - Community
- 6 7 8 9 10 II 12
Free - Analysis Thimphu to Tongsa ‘rongsa Rabdev / Tashicholing Gomdev Tongsa to Nvimshong Nyimshong to Tongsa Tongsa to Damphu Kunea Rabten — Lanetel -Nvimshone Comm. Nunnery - Tongsa Rabdey
13 14 15 16 17 18 19
. . . . - Tsirane — Chanauti - . . I sirang - Rabdev Tsirang — Tsokhana Isirang — Shemjong Thimphu to Bumthang Burnthangto Mongar Comm~nit\’ Halt rliiniphu Community Community . Damphu to Thimphu
20 21 22 23 24 25 26 Mongar— Dremetsi Mongar - Rabdey Mongar — Kadam Mongar - Ngatshang Mongar - Bumthang Bumthang Rabdey / Halt Thimphu
Gompa Shedra . Kurley Lhakang Bumthang - Thimphu Anal~sis
27 28 29 30 I
Punakha Rabdey Analysis Analysis Analysis Punakha - Thimphu
RHP Report I Introduction 16 RHP Evaluation Report - Introduction
RHP Evaluation May/June 1999 Field Work Sites
Package I Package Ia. Package 2 Package 3 Package 4 Total in each zone
Inst. — HW + SW Inst. — SW only Inst. - HW only Inst. - none Community — SW only
Thimphu — Tango 5 sites Shedra Paro - Rabdey
Chuka Rabdev Paro - Keela Gompa Chuka - Chapcha Community
Tsirang — Rabdey Punakha - Rabdey Tsirang —. Tsokhana Zone~ 5 sites C 0111111Unity
Tsirang — Sheinjong Coinniunit
Tc irang — Chcinauti Community
Tongsa — Rabdey Bumthang - Rabdey Tongsa - Nyimsliong Zone 6 sites Tongsa - Kunga Community
Rabten Nunnery - Tongsa — Langtel, Buinthang Kur/ey Tashicholing Goindey Lhakang
Mongar — Rabdey Mongar — Ngatshang Zone 4 4 sites Mongar — Dreinetsi Shedra Shedra
Mongar — Kadain - Goinja 7 Institutions 2 Institutions 3 Institutions 2 Institutions 6 Communities 20 sites
Note: Nine additional sites given in italic
17 RHP Report I Introduction RHP Evaluation Report - Introduction
Logistics: The RHP Office of Dratsang Lhentsog ensured that all necessary permits and letters of introduction were available as required by the evaluation team which was a great help in the smooth running of the field work programme. Dratsangs, health services and dzongkhag administrators were all informed in advance of our visit to each location.
The evaluation team was able to fulfil the revised field workplan due to the assistance given by the district Dratsang and health staff At each location the sample group to he interviewed were called according to our requirements. In some locations we visited people in the village and in other places the villagers were called to us or-were visiting the BHU or Gompa. At each site, the following minimum sample of people were interviewed: - -
Tool 1 observation and information from tile senior person interviewed Tool 2 two religious practitioners, trained or untrained Tool 3 or 7 two religious practitioners, trained or untrained Tool 4 or 8 the senior representative of the religious institution or community of religious practitioners Tool 5 the health worker for the community Tool 6 two community people Tool 9 tile DHSO
Sample: In some locations an additional person was available for interview and, if tlley fitted tile criteria, we took the opportunity to include them in tile sample. Throughout the field work tile evaluator kept track of tile emerging sample, considering the balance of trained and untrained religious practitioners interviewed and tile balance of male/female community people by age and by town or remote. Tile final sample range is fairly representative of all the variables being considered. Some variables are given below:
Sample Range by Tool Used
Trained Untrained Male Female Total Age range Age range Tool2 18 22 36 4 40 I 7-74 yrs 2 1-42 yrs Tool 3 12 -18 36 4 30 I7-55 yrs 2 1-42 yrs Tool4 8 6 IS I 14 29-78 yrs 42 yrs Tool 5 26 Tool6 26 17 43 25-78 yrs 20-70 yrs Tool7 9 5 14 0 14 ~ 32-74 yrs Tool8 5 I 6 () 6 3 5-74 yrs Tool9 7 0 7
The full details of tile sample range by package aild tool used is given in tile Sample Range section of tile Evaluation Analysis document.
A total of 180 separate interviews were conducted with 137 different people. Tile full list of people interviewed at each site is given itt the Sample Range section of the Evaluation Analysis document.
RI-IP Report I Introduction 18 RHP Evaluation Report - Introduction
Tile sample range included some people who represented more than one category from religious practitioner ilealth and community groupings. For example:
Religion community llealth RHP and VHW trained Gomchen I I I I RI-IP trained female village elder I .1 VVHW Pandit, not RHP trained I I I X Gelongs as RHP facilitators I I I-IA’s as RHP facilitators I \~l-IWgelong, not RHP trained. I Ix
Some of the village health workei’s were interviewed as community people and sometimes as tile health representative for tlleit’ community, where there was 110 BHU facility. In several cases the Vl-IW who are religious practitioners were interviewed as health workers and some others were interviewed as religious practitioners. Tile choice was based on covering tile full sample range for each site.
Questions: Throughout tile fieldwork the tools ilad to be used with some flexibility since some of tile questions produced very similar answers as they were originally wot’ded. or caused some confusion wheml translated into Dzongkha. For example:
6.3 If you do practice good health and hygiene habits (including going or not to the BRU). why do you? 6.4 Do you think having good health and hygiene habits is important? If so, why? Ifnot, why not?
Questions 6.3 and 6.4 were reworded during tile fieldwork to focus on what made people change their I-l+H habits (qu.ô.3) and why 1-1+1-i habits are important compared to 110w things were before good H+l-i were practised (qu.6.4).
Question Usual response
6.8 \Vho do you turn to for advice when Medical advice and puja - -
someone in your family is ill? --
I-IAVE YOU RECEIVED HEALTH NO (in which case qu.6.I 1 is not asked)
ADVICE FROM A MONK LATELY? - Re-worded as 6.1 I On what occasion did you receive “Have you or anyone you, know had a sickness in the family?”
health or hygiene advice from a - , What was the problem? monk (e.g. puja for illness. - childbirth. death, or other occasion)? “What did you do?” “What did the religious practitioner do / advise?”
Data Analysis: Some data analysis had been started during tile fieldwork as a. UNICEF laptqp computer was provided , ‘which was invaluable. - -
Data lronl all tile itlterview papers Ilas been ta~hulatedand transcribed and is presented ill tile livaluatioll Analysis document as raw data. The raw data was-then used to identify im3dicators for each of the 19 Key Questions originally drawn up by UNICEF. Tile INDICATORS and CON(’L.USIONS for cacil KEY QUESTION are presented. The MAIN CONCLUSIONS are tilen drawn from tile Key Question Analysis.
19 RHP Report I Introduction RH1~Evaluation Report - Introduction
Evaluation Limitations
Several limitations were identified ill tile evaluation methodology document. They are:
Unfortunately, evaluation results will not be able to say with any degree of certainty whether the RHP has had any impact on the Long-term Objective, namely improved mother-and-child health, primarily because:
- No baseline date on the pre-project mother-and-child health situation in specific project intervention sites was collected.
- No research was done to establish the influence, if any, and the degree of influence of monks and other religious practitioners on niotlier-and-child health, as opposed to myriad other possible influences such as the availability of health care, health information campaigns, general education levels, and so on.
For example, the evaluation may well find that water and sanitation facilities are maintained and used, that monks are cleaner and healthier, and that they impart health messages whenever possible. Though one can make the valid assumption that these achievements result in a net benefit for monks and even their communities, one cannot conclude that, specifically, mother-and-child health has improved nor that improvements are due to RHP specifically.
- C.Marrs, May 1999
Other linlitations require commeilt, arising from tile field work and evaluation analysis process. -
Evaluation team - constraints: Tile need to employ two external consultants with contracts that were not able to overlap was an unavoidable circumstance. This places linlitations Ofl tile evaluation because the evaluator was not able to share tile perspective or insights of the design consultant. Tile rationale for son~eof the methodology may ilave become lost or cilailged from the original intention. Likewise questions may have similarly lost SOttlC of the original design purpose, as may tile process of analysis. This is acknowledged but was unavoidable.
Translator: It was unfortunate that a Bilutanese national could not be i’ecruited as evaluator and that it was therefore necessary to recruit a translator to accompany the evaluator. Tilere are several linlitations: • tile obvious information loss whell questiolls cannot be asked atld answered direct • the inexperience aild immaturity of tile translator (though he worked diligently, had a pleasant interview manner aild was an able translator) • the possible bias in the interpretation of responses (the translator asked and told tile
answer to tile questions tinle and again — did he pick out the common repetitiolls 01’ tile individual nuances ill answers given?) It is not possible to know what was lost or biased by having to work through a translator.
Two illteresting occurrences relate to tile issue of translatillg. One conlnlullity person who was interviewed was visiting tile town from a quite reillote village. The interview took place ill a tea sllop in the bazaar witil the conlnlunity person. the evaluator, tile translator and a geiOllg from the Rabdey. The interview was conducted in four different languages with only two of any of the four people gatilered being able to speak directly with each otiler:
community person gelong translator ~ evaluator
RI-IP Report 1 Introduction 20 RHP Evaluation Report - Introduction
Tile second incident involved tile use of a temporary translator in one location. A health worker was asked to stand ill as translator for some of the interviews as the official translator was unable to attend. He knew tile people being interviewed, through his work contact. He also had good comnlunicatioll skills and knew the subject of H+H well. With this small sample of interviewees the responses were so similar to the translations of tile original translator that the evaluator believes this did not bias tile results. It did serve to clarify that the original translator was achieving satisfactory and valid results.
Interviews: On several occasions during the interviews it was not possible to interview people individually without an audience of son~esort. This was due to the places in which tile interviews were conducted:
MCH clinic roadside Prayer hall school classroom BHU a nunnery prayer room and private quarters Dzong during a Tsechu hospital village houses (in one of which there was an annual puja In progress) Gompa during a puja shop front
The only interviews in which it was possible to insist on being left alone were the Health Knowledge Tests. Generally the interviews did not seem to be affected by one or two curious observers. Several times tile Lam attended during interviews with gelongs, which clearly made them nervous. However it did not seem acceptable to ask tile Lam to leave.
Tools: Tile evaluator felt at times that the evaluation tools, while being very comprehensive and well prepared, were a little too over’-cornpiicated and sophisticated for the task in hand. Tile evaluator has followed tile guidelines for the evaluation methodology entirely. However at tinles there was SOtll~confusion created by having:
- 19 key questions impact analysis categories A and B
- 9 tools to account for different stakeholder groups
- 4 (later 5) packages containing different combinations of the 9 tools with variations ill some of tile questions for eacil different package.
The evaluation package prepared by tile consultant ilas also been used for this analysis. The same comments hold for tile complexity and sophistication of tile evaluation package.
This limitation relates back to tile linlitation raised earlier, of the-design and evaluation being undertake.n by two consuitants with little excllange of illsight into the design thinking.
The results of the evaluation objectives are valid. Triangulation verified tile consistency between tile views of religious practitioners, conlrnullity people and health workers. Comparisons between trained and untrained religious practitioners were also possible for SOfllC of tile evaluation. All the impacts are shown to be positive and tile evaluator has therefore introduced a conditionality to each key question, which describes the most significant condition, whicil enables tile impact to be positive.
Sanlple: Paro was selected as a control site since there has been no hardware or software illput (or very little!). Anotiler control group which, in hindsight, would have been more representative would ilave been a community where tilere has been no input (religious comnlunity witil no RHP trailling/no easy access to health services) since the community people are tile ultililate beneficiaries of the inputs. No remote communities with no inputs were visited.
21 RHP Report I Introduction RHP Evaluation Report - Introduction
Other I-I+H inputs: Concern was expressed by the Stakehoider Committee (lOhhl May 1999) tilat sites in which there had beell UNFPA interveiltions would distort tile findings for the RHP evaluation. The IJNFPA training is similar to that of RHP. Of the sites visited for the RHP evaluatioll Punakha and Tsirang are the only districts to ilave received both RHP and U’NFPA inputs. Stakehoiders agreed tilat RHP evaluation sites could coincide witllUNFPA sites, since the evaluation results of sites with UNFPA intervention would in a sense confirm (or not) the validity of RHP strategies.
The evaluator observed that tilere ilave been a number of H+H inputs over recent years. Sonle beneficiaries are very clear as to the source of the input. otilers are quite unclear as to the funder.
Baseline illdicators of religious practitioners llealth knowledge: As there is 110 baseline measure of the level of knowledge the religious practitioners ilad before RHP training it is only speculative to say that the level of knowledge of ulltrained religious practitioners as measured by the Health Knowledge Test will give some indication of tile pre-RHP training levels of knowledge among religious practitioners. Other factors will include: • the religious practitioner’s level of basic education • their exposure to other sources of health information, and • tileir access to other trailling, for example some religious practitioners are also trained as VT-lw.
Note: Terminology used throughout the Evaluation Report and Evaluation Analysis: I. RHP is used to abbreviate reference to tile Religion and Health Project.
2. The ternl religious practitioner has been used as an inclusive ternl referring to monks and community-based religious practitioners collectively. When reference is made to a specific category for example Gomcllen or gelong, this term is used explicitly.
3. FFL and HOH is used to abbreviate tile titles of tile two main health publicatiolls used in tile RHP worksllops, Facts for Life and Health in our Hands.
- 4. 11+1-1 is used to abbreviate reference to health and hygiene. 5. SW and HW are used to abbreviate Software (ie. RHP trailling) and Hardware (ie. water and sanitation facilities)
RI-IP Repon I Introduction RHP Evaluation Report — Key Questions
Key Questions
Stemming from the above evaluation objectives, a number of Key ‘Questions were developed. For analysis purposes, these key questions will he grouped according to whetiler they correspond to finding out about: A-Behavioural Changes in Religious Communities, or B-Effective Performance of Religious Comnlunities as llealth promoters.
The Key Questions are as follows: a) Role otreligious COlflmUfliIieS in j)romoting health: al) Is tile health promotion role of the religious community (ordained nlonks) and/or comnlunity-hased religious practitioners understood by themselves (and by the commullity and by health workers)? a2) How successful have tile religious community and/or community-based religious practitioners been in their role as health pronloters (views of religious communities themseives, community nlenlbers and health workers to be asked)? a3) Do the religious comnlunity and/or community-based religious practitioners feel that they can contribute more ill promoting health? If yes. what more and 110w? a4) Do community—based religious practitioners (such as tsips, /X1WOS, paifloS, gonwhens, /akri,s) view tile role being pronloted by tile RF-IP as a threat to tileir livelihood? (above cited people are usually approached in times of ill health to perform rituals/pujas and get paid in casil or kind for their services).
Ii) Behaviou,’al changes in the religious c’omlnunity:
hi) Are there changes in tile llealth seeking and hygiene practices of the religious community and/or community-based religious practitioners after RHP training workshops? b2) I--low have tile impi’oved water/sanitation facilities been used and nlaifltailled? 113) Have tile religious comnlunity’s attitudes towards sanitation and hygiene cilanged with tile introduction of illlpl’Oved water/sanitation facilities? b4) Do the religious Cofllmullity and/or community—based religious practitioners provide advice Ott healtll care when approaciled for religious services ill tile event of family iilIlesS?
c) Behavioural changes in the community:
ci) Do conlnlunity lllemhers receive health advice fronl tile religious conlmullity and/or comillullity-based religious practitioners when approached for religious services in the eveilt offanliiy illness? c2) I-las tile religious conlmullity and/or the conlmunity—hased religious practitioners influenced the health seeking and ilygiene practices of tile conlmunity? c3) Are tilere any added advantages of the religious conlmunity and/or community-based rd igious practitioners prolllotillg health? c4) Arc there changes in the health seeking and Ilygiene practices of the religious community and/or comillunity—hased religious practitioners after RHP training workshops?
23 RHP Report 2 Key Questions RHP Evaluation Report — Key Questions ci,) Health workers’ views: dl) Rate tile effectiveness of the religious comnlullity and community-based religious practitioners as promoters of health messages. d2) Do health workers view the religious community and community-based religious practitioners as competitors or complementary? d3) Has there been an increased number of patients from the conlmunity referred by tile religious community and/or community-based religious practitioners following RHP
workshops? - e) Et,feclivenes,s of training workshops: el) What knowledge has been retained by religious persons who attended RHP training workshops? e2) What is the knowledge of religious persons wllo Ilave not been trained? e3) What additional areas of health would tile religious community and/or community- based religious practitioners like to learn about in the training worksilop to enhance their role as health promoters? e4) How can training workshops be furtiler improved?
Note: Format of Key Question Analysis
Each Key Question is now considered against tile evaluation findings.
Information relating to each Key Question is presented as INDICATORS and CONCLUSIONS.
For each Key Question the views of tile religious practitioners, community people and ileaith workers are considered, as appropriate.
For eacil INDICATOR, the TOOL REFERENCE is given. Analysis of each Tool is presented in the Evaluation Analysis document.
Tile impact of tile Religious and Health Project is given for eacil Key Question using tile two analysis categories given in the evaluation design: .4 nalysis A: Positive Behavioural Changes in Religious Comn2unitie.s .4nalysis B: Effective Per,fbrinance ofReligious Communities as Health Promoters in their Communities
For each statement of impact, a statemeilt of condition is given ie. tile maul condition which Ilas to he met in order to achieve a positive inlpact. Tile MAIN CONCLUSIONS and the RECOMMENDATIONS are a summary of tile Key Question conclusions, given at tile end of tile section.
RHP Report 2 Key Questions 24 RHP Evaluation Report — Key Questions
Key Question al. - Role of religious communities in promoting health Is the health promotion role of the religious community (ordained monks) and/or community-based religious practitioners understood by themselves (and by the community and by health workers)?
View of Religious Practitioners Indicators: • 39 out of 40 religious practitioners interviewed said that tiley provide H+H advice in their community
[Tool 311 hoot 7/5 YN — closcdi • Conlments from the religious practitioners indicated a reasonable level of H+H
knowledge and awareness of H+H issues - [Tool 3/Tool 7 site profiles - openl • Tile religious practitioners made the following comments: ~ Health advice can be given when making home visits for puja ~ The young monks are taugilt to tell their parents H+H messages ~ rile double message fi’om the religious community and tile health workers leads to improved standards of health ~ People will mostly follow the advice of the religious person even if the advice has been givell by tile healtll worker ~ If called for a puja and there is a sick person they advise the person to go to the hospital ~ When givillg nlessages and teachings in the conlmunity tile mOllks should be clean to
- set a good example - ~ Once a month tile trained anim is sent to remote communities to give H+H n~essages =~‘ Before RHP we didn’t have tile knowledge and so we might be in conflict with the health workers if tile astrology said not to do sometiling. Now it’s the same advice ~ If there is some nlisunderstanding with tile conlmunity people the geiong tries to clarify. For example people thought that medicine was poison; now with training even his doubt is clarified ~ If Lanl asks people to construct a latrine or call tile llealth worker or take tile patient to ilospital tiley will do it ~ Tile training of the monk body in H+H ilas influenced to the grass roots level not
otherwise reached - [Fool 31Fool 7 sic profiles— openi
l’Fool 4IFool 8 - open View of Community People Indicators: • 32 out of 40 conlnlunity people said tiley appreciate tile religious practitioners’ contribution to health Illatters ill the community. File 8 remaining responses were 11011- committal and were from sites where there have been minimai or no RHP training programmes
Ilool 613 — elosedi • The conlmunity people made the following comnlents: =~ if tile monks have health knowledge they go to tile villages and they can be tile bridge between the village and tile medical people ~ Some people oniy consult tile religious practitioner, so they (the religious practitioner) can identify whetiler tile person SllOuld seek medical advice • Other comnlents suggest tile role of the religious practitioner as health promoter is not fully understood by some conlmunity people:
25 RHP Report 2 Key Questions RHP Evaluation Report — Key Questions
=s First they go to the Jakri who will tell if they should go to tile BHU or the hospital. If it is a fever the Jakri will do a little puja and then immediately send to the hospital. If it is psychological he will do puja for 2-3 days. =~ Monks will not have medical knowledge and cannot force people to go to tile clinic
Tool 68/9 — opeii I View of Health Workers Indicators: • 20 out of 22 health workers considered that health and hygiene habits had been influenced by the llealth promotion activities of the monks [Fool 514- closed I • Tile health workers made the followillg comments:
- - Tile role is only to advise people to go for medication ~ 60-70% are advising to do puja and come for medication. Before they came for Illedication too late
=~‘ We call the gomchens the health motivators — they are the first to see tile sick person
~‘ What the monks say is taken up by the community — their one word to our three
=~‘ More remote places are not Illuch improved. They need tile RHP training
~ Local healers need training especially -
- Tool 5.8 — open I
Conclusions - - al: The role of the religious community and religious practitioners as health promoters is understood by themselves, by community people and by health workers.
The religious community -indicated tilat they have been giving H+H messages but that referral to tile BHU or hospital is a new role since RHP. Some health workers indicated tilat tilere is a change in this respect anlollgst hotll gelongs and religious practitioners in the commullity but that there is still a delay in referral in S0Ill~cases. There are two possible reasons for tile differeilce in perspective. First, many of tile religious community stated positively that they do botil puja and, refer for medical advice but tile evaluation did not pursue wiletller there is still some delay while the puj~actually takes place. Sonle- religious practitioners nlentiolled categorically tllat they do a very silort rnantra and refer quickly if the case is urgent. Secondly, many religious practitioners qualified tile referral for medical ,advice by stating that referral would always be the case if tile PC~50Ilhad a disease but that a spiritual sickness would require puja, tllen medical advice. The evaluation did not manage to clarify how tile religious practitioner IlligIlt distinguish which sickness required medical advice more urgently. Tile cornmellt from several HA’s suggested tilat a fever lllight trigger referral advice whereas ARI for example is still not takell seriously enough.
The response from tile community illdicates tileir complete trust in the word of the religious practitioners and that they will advise correctly to tile community on healtil matters. This higillights tile importance of tile role of tile religious practitiollers in the community and therefore the importance of training such as tile RHP workshops to im~rovetheir knowledge and understanding of ilealth issues. -
Analysis B: Effective Performance of Religious Conlmunities as Health Promoters in their
Conlillunities -
Key question al = POSITIVE IMPACT - - -
Conditional: RI-IP training is a key to grass roots health promotion -
RI-IP Report 2 Key Questions 26 RHP Evaluation Report — Key Questions
Key Question a2. - Role of religious communities in promoting health How successful have the religious community and/or community-based religious practitioners been in their role as health promoters (views of religious communities themselves, community members and health workers to be asked)?
View of Religious Practitioners Indicators: • Health knowledge test scores range from 7O% to 1 OO% with an overall average of 87%. There was very little difference between the scores of trained and untrained religious practitioners (See el/e2 for furtiler analysis of test scores)
[Tool 2 - tcstl • 39 out of 40 religious practitioners stated tilat they are providing H+H advice to their community, 13 of wilolll were not doing this prior to RHP and a further 1 7 did not receive
training - • 7 of tile 21 religious practitiOllers wilo attended RHP training were practising good H+H Ilabits prior to tile trailling, ill their view. • 39 out of 40 religious practitioners feel confident in providing health advice • 39 out of 40 religious practitioners enjoy giving health advice • None of the religious practitioners saw providing health advice as a burden • All tile religious practitiollers saw providing health advice as benefiting the community - - [loot 39—Ifibfool 7 3~0 — open] • Tile religious practitiollei’s gave the following indicators of tile success of RHP:
~ Increased level of knowledge and understanding of H+H - ~ Change of living standards ~ Cleaner living environments =~s More people seek advice from the health workers
~ People are not so sick -
Ifyou keep on giving the same message at last the villagers follow the advice. Then they realise the benefits for themselves and they will continue the good habits.
- - Then it is successful Comments from a religious practitioner
irool 3 — open] View of Community People -
Indicators: - • 31 out of 40 conlnlunity people think that the religious practitioners have been successful as Ilealtil promoters. Tile remaining 9 people didn’t know (8) or had no contact with
religious practitioners (I) - Tool 614- closed! • The community people made the following comments: ~ Tile monks are very effective at giving medical advice. If tile health worker advises
to go for medical treatment the villagers will make excuses not to go. - ~ A child was sick witll diarrlloea. The Pandit told him to give boiled water and fresh food. Tile VI-IW said to keep tile surroundings clean and keep ut~nsilsand lillen
clean. Tile child got better without having to go to tile hospital. - ~ Before the RHP son~êvillagers would go for medical advice as well as puja but sometimes a person would die if only puja was performed
- — [Fool 6 — open]
27 RHP Report 2 Key Questions RHP Evaluation Report — Key Questions
View of Health Workers Indicators: • 20 out of 23 health workers considered the role of the religious practitioner as health promoter to be successful. Those who responded that tile role has not been successful either stated there is more still to do or that RHP is not the only reason for success in communicating health messages. Fool 517— closed! • The health workers made the following comments: =~ 60-70 % of religious practitioners are advising people to do puja and con~efor medication. Before, they came for medication too late. ~ Regular follow up is needed. Tile religious practitioners are capable and if you follow up they will continue. If you leave it they will too.
RHP is not yet successful. Still only a few are trained and they only have a small knowledge. They don’t worry about diarrhoea. They only worry about the high fever eases. There are still a lot of health messages to teach. Comments from a health worker
loot 5 — open~
Conclusions - a2: The religious community and/or community-based religious practitioners have
been successful in their role as health promoters — view of the religious community community people and health workers
Tile religious practitioners’ level of kilowiedge coiltrihutes to tileir success as lleaitil promoters. Tileir response to the role is very positive. Those wilo ilave been invoived are enthusiastic and those who have not yet participated expressed an interest to do so silOuld tile opportunity arise.
The religious practitioners are advising ~n a range of H+H issues, in some cases following up and supporting the initiatives of tile headman or health worker, for example with latrine construction, and ill other cases giving messages 011 cleanliness, early referral and STD/AIDS, etc.
Thougil tile messages indicating success are very positive other points were raised. Tile religious practitionel’s are not all capable or interested ill conlnlunicating healtil messages. they are not all trained. and not all tile religious practitioners from monastic illStitutions work regularly in tile comnlunity. These points are further considered ill tile strategies for future trai ni11g.
Tile assessment of “successful” is very subjective and is based on perspective and expei’ience. The perception of success may vary between religious practitioners, community people and health workers. Whatever the interpretation tile COI15CI15U5 indicates success, but there is more that can be achieved.
Analysis B: Effective Performailce of Religious Comnlunities as I-Ieaith Promoters in their Communities
Key questioll a2 = POSITIVE IMPACT Conditional: Ri-IP is one of a number of H+i-I inputs. More can still be done through Ri-IP.
RHP Report 2 Key Questions 28
, RI-IP Evaluation Report — Key Que~tions
Key Question a3. - Role ofreligious communities ii~promoting health Do the religious community and/or community-based religious practitioners feel that they can contribute more in promoting health? If yes, what more and how?
View of Religious Practitioners Indicators: • Yes what more? Some comments: ~ More messages on sanitation and hygiene =~‘ Continue the same messages encouraging people to take medicine as well as puja
~ If tilere is more training we can do more — new information or refresiler
~ We could take ~n the VHW role - ~ If the manual was ill Nepali we could read it
• No wily not? Some comnlents: - =~ With no facilities the role can only be this much ~ Medical advice silould be given direct by the HA ~ Some topics are forbidden in Buddilist teachings aild it is difficult for tllonks to speak out eg. STD/AIDS, pregnancy and family planlling ~ May not be able to fulfil more ~ Gomchens have their own farm work to do. so it is difficult to see how they could do more ~ Sonle can hut would not want to or have a different way of thinking ~ Jakri sllouid not do the VHW type of role
tool 49/87 — open]
View of Community People Indicators: • 28 out of 40 cornnlunity people feel that religious practitioners can contribute more in promoting health. 1 2 said they don’t know.
Fool 615 — closed! • Yes what Illore? Some comnlents: ~ More facilities for tile religious practitioners ~ Give medicines
~ More trailling = more kilowledge to pass on, especially early referral
~ irain at tile gewog level especially the powas and pams — they don’t like to leave the village ~ Make the role more official • Yes wllat more for general health promotion?: ~ Train labour officers: more trained VHW’s: more hooks Fool 616 — open I View of Health Workers Indicators: • 23 out of 23 Ilealtil workers feel that religious practitioners can coiltribute more in prollloting health I ool 5l~)— closedj • Yes what nl0re? Further comments: ~ Monks should be aware of the ilealtil worker role and then, if well informed, they can support us and impart some knowledge
29 RHP Report 2 Key Questions RHP Evaluation Report — Key Questions
There have been improvements but more is needed — and time too. It is not satisfactory yet. Need to stress more on~keepinganimals separate. Communities are not happy to do this. Also need budget to do this.
-- [Tool.5 - open]
Conclusions a3: The religious practitioners, the community people and the health workers generaftv feel that the religious community can contribute more in promoting health
The religious practitioners have different views on the extent oftheir role and commitment to it. The general view was that what can be done “onthe way” is sufficient. Some were more enthusiastic but many responses suggested that this and- the continuing motivation is dependant on some incentive, for example further training and materials such asFFL and HOH, maybe even some recognition and follow up is sufficient.
The community are keen to see more improvements but identif~rless directly withRI{P unless they have had some direct link with the project, for example several headmen and village women interviewed had participated in the gewog level RHP.
The health workers are perhaps in the best positionto give more constructive and focussed guidance on this question in future. This will be raised again in the Future Strategies.
Analysis B: Effective Performance ofReligious Communities as HealthPromoters in their Communities Key question a3 POSITIVE IMPACT Conditional: Interest and ability varies between individual religious practitioners.
Bath house at Tsirang Rabdey
RHP Report 2 Key Questions 30 RI-IP Evaluation Report — Key Questions
Key Question a4. - Role of religious communities in promoting health Do community-based religious practitioners (such as tsips, pawos, pamos, gomchens, jakris) view the role being promoted by the RHP as a threat to their livelihood? (above cited people are usually approached in times of ill health to perform rituals/pujas and get paid in cash or kind for their services).
View ofCommunity-based Religious Practitioners Indicators: • All 6 community based religious practitioners responded that tile role being promoted by tile RHP is not a threat to their livelihood. 5 out of 6 had attended RHP training.
tool 89 - closed] • The col-nnlunity-hased religious practitioners made the following comnlents:
~ First the normal religious practices are followed. - Then if there is no improvement the
person seeks medical advice. - ~ Learning is a benefit to yourself ~ If no client is coming they feel comlortable ~ It is not a threat because it is not going against tile religion. It’s just giving health advice =~‘ We can do both (medical advice and puja) side by side
I l~ol89 — oPe1i I Conclusions a4: Community-based religious practitioners (such as tsips, pawos, panios, j~omche,,s Iakris) do not view the role being promoted by the RHP as a threat to their livelihood
The sample interviewed is small and may not he representative of the general view or of the view held in more reillOte communities. As a linlitatiOn of tile evaluation it is iloted that the sample did not include any religious practitioners fronl the more remote comnlunities where for example access to BHU facilities are difficult and RHP training has not been received. Whether the religious practitioners interviewed had thought of this as a threat prior to the RI-IP trainillg is not establisiled but their view is unanimously positive now. Whether the religious practitioners have another main source of income (cash or kind) other than iflcollle from their religious works is again not estabiisiled from tiliS evaluation. A religious practitioner with little other source of income may be more threatened and this may well
apply to those ill tile more renlote locations. -
Anal sis B: Effective Performance of Religious Comnlunities as I-Iealth Promoters ill their Communities
Key question a4 = POSITIVE IMPACT Conditional: none
It only takes 2-3 days to make a pit latrine If you fall sick how many days ofwork will you lose? Comment from a Pandit
31 RHP Report 2 Key Questions
, RHP Evaluation Report — Key Questions
Key Question bi. Behavioural changes in the religious community Are there changes in the health seeking and hygiene practices of the religious community and/or community-based religious practitioners after RHP training workshops?
View of the Religious Community - -
Indicators: - • All 21 religious practitioners who had participated in RHP training adopted some new
H+1-1 practices after the workshop. - • Of the 21 RHP trained religious practitioners 8 were giving ilealth messages prior to Ri--IP and one is not in contact witil tile community. • 12 out of 21 religious practitioners changed their practice of giving H+H advice to tile collinlunity as a result of the RI-IP training
• Of the 15 sites visited witil hardware facilities the following was observed:IFool 311/7.5—6 . closedI
adequate condition not adequate condition
W iler Supply (tap 12 ofwhich 4 UNICEF funded 3 of which 0 UNICEF funded stinds) ~
Water Tank II ofwhich 1) UNICEF funded 4 of which 0 UNICEF funded
Water 1-leater none None
Bath House - 5 of which 3UNlCEFfunded. -:2 ofwhich1 UNICEF funded
Latrine 6 o~vhich3 UNICEF funded - - 9 of which6 UNICEF funded
Septic Tank 8 ofwhieh 2UNICEFfunded -- I of which 0 UNICEF funded
Drainage 9 of which 1) UNICEF funded 3 of which 0 UN ICEF funded
Electricity 12 of which 0 UNICEF funded 0 of which 0 UNICEF funded
Kikhen Improvcment 6 of which 3 UNICEF funded 3 of which 0 UNICLF funded
Biimthang Stove 3 of which 2 UNICEF funded I of which 0 UNICEF funded
Garbage Disposal 9 ofwliicli 0 UNICEF funded 2 ofwliich 0 UNICEF funded
Dustbin S of which 0 UNICEF funded 2 of which 0 UNICEF funded
~‘ See site reports for fltrther details ~ lo sumnlarise. the essential facilities for good H+H practice (water supply, latrine and kitchen improvement) were all to SOill~extent inadequate, ill some cases tile CoilditiOll of UNICEF funded facilities were ftulld to he inadequate (See Evaluation Analysis Tool I Site Profiles for further details) IIool I 2—closed I • ftc religious practitioners made the following comments: ~ Before in the Dzong you used to see dirty hands. feet and clothes. Now you don’t see tili 5
RIIP Report 2 Key Questions 32 RHP Evaluation Report — Key Questions
Previously the monks had to go far to get water so it wasn’t easy to keep clean =~ After the training most people made proper drainage and kept their houses clean ~ H+I-I llas improved even from before RHP due to tile influence of health staff from the BHU and the VHW
[loot 4.2/82 - open I
Conclusions bi: There are changes in the health seeking and hygiene practices of the religious community and/or community-based religious practitioners after RHP training workshops ftc changes in 1-1+1-I practises of tile religious community are denlonstrated in their awareness of the H+H issues aild ill some cases observation of monks cleaning teeth or waSiling latrines, etc. Tile changes are, at least ill part, a result of the RHP workshops. H+H messages have been comnlunicated through a variety of channels including BBS broadcasts, Kuensel articles, active District officials and headmen, government circulars and RHP worksilops supported by water and sanitation facilities.
There are some collstraints to good I-1+H practice which are outside tile control of tile religious practitioners. For exalllpie in some cases the water and sanitation facilities are not adequate for tile population or have not been upgraded, in some places the water supply is not adequate or tile seasonal variations do not always provide for a nutritious diet. The religious practitiollers demonstrate their awareness of H+H by stating tilese factors as constraints and the attitude now is that tiley would like to have the means to practice good H+H habits.
Allalysis A: Positive Behavioural Changes in Religious Communities
Key question hi = POSITIVE IMPACT - Conditional: H+l--I practices are changing where facilities are functioning
ii RHP Report 2 Key Questions RHP Evaluation Report — Key Questions
Key Question b2. - Behavioural changes in the religious community How have the improved water/sanitation facilities been used and maintained?
View of the Religious Community
Indicators: - • Of the 15 sites visited with hardware facilities the following was observed:
Cleanliness adequate Cleanliness not adequate
General IS - 0
Latrine 11 of which 6 UNICEF funded 4 ofwhich 3 UNICEF funded
Bath House 6 of which 3 UNICEF funded 0
Kitchen Hygiene 12 of which 3 UNICEF funded 3 ofwhich 0 UNICEF funded
Waste disposal sites IS of which 0 UNICEF funded 0
• To summarise, tile essential facilities for good H+H practice (latrine, bath house and kitcilen improvement) were generally kept adequately clean. In three cases the condition of UNICEF funded latrine facilities were found to be inadequate due to over population and uncertainty or inaction when the facility becomes full. (See Evaluation Analysis Tool I Site Profiles for further details)
Ilool I .5 I — closed • 25 out of 28 monks help to keep the water supply clean and maintained
• 21 out of 26 monks help to keep the water tank clean and maintained — 2 do not have this facility
• 6 out of 8 monks help to keep the bath house clean and maintained — 20 do not have this facility
• 26 out of 28 monks help to keep the latrine clean and maintained — 2 have shared Dzong facility
• 17 out of 28 monks help to keep the garbage disposal clean and maintailled — Ii Ilave shared Dzong facility
• 17 out of 28 monks help to keep the dustbin clean and maintained — II have shared Dzong facility
- Ilool I 3 — elosed I • Issues relating to use of water and sanitation facilities— comments =~ The water source and latrille (used also by the public) are outside the Dzong. File doors of the Dzong are locked at night so tile gelongs cannot go out ~ The number of gelongs using tile facility ranges from 100 during the summer months to 1000 for a major puja
=~‘ There is always a rush -for tile taps before mornn~gprayers — not enougil taps and not
enough time - ~ The latrines are not pleasant to use
• Issues relating to maintenance of water and sanitation facilities — comments ~ If training, tools and budget were available the Dratsang could maintain tile facilities =~ One gelong was trained in piunlbing and has some basic tools ~ Tile water tank is open at tile top aild they ilave had dead rats and live frogs inside tile tank
RI-IP Report 2 Key Questions 34 RHP Evaluation Report — Key Questions
=~ Unclear who should maintain, the Dratsang or the Dzongkhag Administration =~ The water source is fenced. The monks inspect the tank regularly and clean if necessary =~ The Dzong sweeper empties the dustbins • Exanlples of use and maintenance problems: =~ Water pipe damaged from a landslide
~‘ Tile water source is dry from November to March - =~ The latrine waste freezes in winter causing a blockage in the pipe =~ Some village people dirty the water by walking and grazing animals near tile source [tool I prolilesltool 44— open]
First has to come the safe water supply. - Then only the 11+11 messages can be practised Corn ment from a health worker
Conclusions - - b2: Use and maintenance of the improved water/sanitation facilities lnfornlation was gathered on all water and sanitation facilities, whether funded by UNICEF or anotiler source (see note below).
Tile general standard of cleanliness was adequate but observation suggested that the evaluator’s visit may have prompted some cleaning up of the facilities. The most common response to cleaning and maintenance of facilities is that minor problems will be fixed by the nlonks or anims hut for major problems a skilled person will be called from the Dzong. Those religious institutions tllat share the Dzong with tile administrative offices also share the Dzong sweeper and plumber for Cleallillg aild maintenance of facilities. Some nlonks and anims have been trained in basic maintenance and have been provided with tools. Several institutions have been givell a fixed deposit by UNICEF. Tile Dratsang has deposited an equal amount and tile interest on tile account provides a fund for maintenance of water and sanitatioll facilities. -
Note: At some sites there was some uncertainty in being able to identify which facilities had been provided with UNICEF funding. In several cases this was due to a change of personnel S11lC~the installation of facilities, but more generally it seemed that-the fullding had been channelled tilrougll the Dzongkhag Administration or Public Works Division and the source of the funding was unknown. Also it was the case at some sites that there had been several sources of funding including UNICEF, RGoB and private donations. Who actually paid for tile ~ tank or tap was unknown. Wilat was known was whether the facility was functioning and associated problems, of which there were some problems to be heard at alillost every location.
Analysis A: Positive Behavioural Changes in Religious Communities
Key question b2 = POSITIVE IMPACT Conditional: Facilities nlaintained where skills, tools and funding are available.
35 RHP Report 2 Key Questions RHP Evaluation Report — Key Questions
Key Question b3. - Behavioural changes in the religious community Have the religious community’s attitudes towards sanitation and hygiene changed with the introduction of improved water/sanitation facilities?
View’ of the Religious Community Indicators: • All 28 gelongs interviewed said that water and sanitation facilities make them feel better • 27 out of 28 gelongs interviewed said either tilat improved water and sanitation facilities have cilanged their attitude to I-T+H or that their attitude would change if improvements were made to their water and sanitation facilities 11001 35-6 — closedI • The religious practitioners made the following conlments: ~ If there is a reliable water source then they can practice good H+H llabits. This is what tiley would like to be able to do. ~ The preference would be to use tile latrine rather than open defecation but due to few latrines they sometimes have to use the jungle or the fields ~ If there were improved facilities then tileir attitude would change. They would feel better if there was water inside the Dzong ~ They know it is good to have good H+H habits but the facilities are not functioning
well -
~ Tile monks are enjoying the easier access to water — they have to wash from early morning when there is a puja and they DO longer have to go down to the water source ~ With improved facilities there would be 100% cilange in attitude. The facilities have to con~efirst. For example, even to make a garden we need tile water first [Fool 3 site pro Illcs/tool 45 — open I Conclusions b3: Changes in the religious community’s attitudes towards sanitation and hygiene with the introduction of improved water/sanitation faciiitics
Mollks are appreciative of improved facilities including the provision of safe water, latrines and water supply for body and clothes wasiling. Those Wilo do not yet ilave improved facilities look forward to future improvenlents whicil will change their attitude to what is presently arduous (eg. collecting water), difficult (for example washing in tile 1 5 minutes between rising and morning prayers) or unpleaSallt (eg. using over-used latrine facilities).
Tilere is little reference made to tile iillpact of improved kitcilen facilities and garbage disposal. Those who have Bumtilang stoves appreciate the conveniellce. Many institutions use a system whereby rice is cooked for all gelotlgs atld mOllks have gas stoves in their rooms to prepare curry and to boil water. institutions ill WiliCil tilere are younger monks gellet’ally cook collectively for all the residents. At puja alld Tsecllu tinles kitcilen facilities are particularly stretciled. in a Ilumber of locations collective cooking is still done on traditional open fires with associated problems of soot deposit, and in several cases there is no open ceiling for the snloke to escape. Tile issue of garbage disposal is discussed further in c4.
Allalysis A: Positive Behavioural Changes in Religious Communities
Key question b3 = POSITIVE IMPACT Conditional: Attitudes change when facilities are improved and are functioning
RI-IF Report 2 Key Questions 36 RHP Evaluation Report — Key Questions
Key Question b4. - Behavioural changes in the religious community Do the religious community and/or community-based religious practitioners provide advice on health care when approached for religious services in the event of family illness?
View of Religious Practitioners Indicators: • 39 out of 40 religious practitioners provide advice to the community. The interview questioll does Ilot investigate what advice is given in the event of a family illness
11001 3.11/75 - closed I • The following comments illustrate the kinds of advice given by religious practitioners:
=~‘ There is a dual systenl of puja and medicine. Puja is the traditional system based on wisdom (sherub); medicine is tile method (thub). We say to the village people the two should not be separated ~ The lilabsang puja is conducted regularly ill the hospital to clear illusions ~ Tile main messages being given to tile villagers are:
• Cleanliness — ifyou doll’t stay clean this will cause problems
• Pregnancy — if you are pregnant then you should go for a check up
• lnlnlunisation — cillidren sllould be immunised against diseases or tiley will suffer
• STD/AIDS — can be transmitted through sexual contact and blood, eg. re-used needles ~ Previously we used to give some basic H+H information during pujas. Since RHP trainillg we have t~~oreknowledge and can give more and better advice
~ When we go for puja and we see uncleanness we give advice - ~ Before RHP we only gave tile traditional advice ~ Some follow tile advice, otilers don’t. Those wilo have listened to tile advice ilave benefited ~ Ifcalled for a puja for a sick person we first see if it is caused by disease. If so we advise to go to tile BHU. Before we didn’t give tilis advice. If the disease is not curable by a puja then we send tile patient to tile BHU
ITool 3[Iool 7 site proliles — openi
Conclusions - h4: Advice on health care is provided by the religious community and/or community based religious practitioners when approached for religious services in the event of family illness
The responses given by tile religious practitioners illdicates that tile H+l-1 messages are being communicated to tile conlmunity during pujas and family illness. It is also clear that the messages are tilose that tile RHP seeks to convey through the religious practitioners and is a cilange of practice for tile religious practitioners as a result of RHP training.
Analysis B: Effective Perfornlance of Religious Communities as Health Promoters in their Comnuinities Key question b4 = POSITIVE IMPACT Conditional: Tile evaluation responses re-emphasise the need for training of religious practitioners in early referral and signs and symptoms of serious illnesses.
37 RHP Report 2 Key Questions
- RHP Evaluation Report — Key Questions
Key Question ci. - Behavioural changes in the community Do community members receive health advice from the religious conlmunitv ard/or community-based religious practitioners when approached for religious sen -i s in the
event of family illness? -.
View of Community People Indicators: • The community people described what advice they have received when there has been a
sickness in the family: -
~‘ A relative was sick and the monks at the puja advised him to seek medical advice. It was only from the medical advice that he discovered it was typhoid. =~ The religious practitioners tell the village people to do puja and then go to the hospital. Before when there was no easy access to medical help, when there was no BHU, they would do puja and if it didn’t work the person might lose their life. It would take more than one day to reach the BHU. Now it’s a 2 hour walk ~ If the sickness is serious then we go for medical advice. If the illness is caused by the spirits then we would go to the Gomchen for a puja which will cure the person ~ If a sickness is not curable we call the Tsip for astrology =~ Puja is for suffering from spiritual problems. Medication does not help for spiritual problems ~ Monks will not have the medical knowledge and cannot force people to go to the clinic
=~ Some peopie perform puja rather than go for medical treatment — even if the advice is
to go for medical treatment some villagers will have many excuses - =~ Religious practitioners give H+H advice during annual puja, collecting alms. reading astrology, Tsechu and when people die =~ There are some diseases where puja is better and other diseases where medication is better. Problems like diarrhoea, stomach ache and body ache the Gomchen will advise to do tile puja and also go to the BHU Irool 6.~-w6III Conclusions ci: Health advice received by community members from the religious community and/or community-based religious practitioners when approached for religious services in the event of family illness
Improved H+H habits are dependent oti improved facilities. So too, for son~ecommunities
and religious practitioners, tile choice between nledicai and religious practices in tinles of - sickness depends on access to facilities. Access to medical facilities is improving rapidly but some people are more reluctant to change their traditional ways quickly. The encouragement of the religious practitioners, in these cases especially, gives strength to the messages from tile health workers.
As in any small community everyone will know of events surrounding a sickness, especially if a visit to the hospital or.BHU is required. The outcome of the visit will also be known and can influence belief greatly. It would seem that the credibility of medical advice is still not as wicleiy and happily accepted by soille as the traditional advice of the religious practitioner. In this dual system it is important tilat the religious practitioners, with the greater and
RI-IP Report 2 Key Questions 38 RHP Evaluation Report — Key Questions unthreatened credibility, are knowledgeable in health and hygiene since people place so much trust in them. -
Note: It was observed in the interviews that people seemed reluctant to relate personal family experiences ofsickness but would more happily tell ofthe fortunes or misfortunes ofothers. Some examples are transcribed in the RHP Evaluation Analysis: Tool 6.
Analysis B: Effective Performance ofReligious Communities as Health Promoters in their
Communities -
Key question ci = POSITIVE IMPACT -
Conditional: The evaluation responses re-emphasise the need for training ofreligious - practitioners in early referral and signs and symptoms ofserious illnesses.
Monks and Community members using the water facilities at Drametse
39 RHP Report 2 Key Questions RI-IF Evaluation Report — Key Questions
Key Question c2. - Behavioural changes in the community Has the religious community and/or the community-based religious practitioners influenced the health seeking and hygiene practices ofthe community?
View of Community People - -
Indicators: -- • 32 out of 40 community people said they appreciate the religious practitioners’ contribution to health matters in the community. The 8 remaining responses were non- committal and were from sites where there ilas been minimal or no RHP training
11001 613 - closedl • All 40 community people interviewed said that they use latrine (no open defecation), wash hands before meals and after the latrine and bath regularly. 37 out of 40 community
people said that they put waste in a pit or dustbin - - [Tool6.2 - closed] • Many comments suggested that there are a variety of influences on community H+H practices:
=~‘ H+H messages learned from school, from health workers, from seeing others with good H+H habits ~ File Dzollgkhag has advised to keep tile surroundings clean ~ The Government provided kidu for animal shelters
~‘ H+H messages were given in the army
=~‘ BBS news and health announcements have explained the problems ~ H+H messages and pictures of a model village in National Day exhibition ~ As Tsokpa, when I go from house to house I give health messages =~ H+H advice received from monks and religious practitioners [Fool6.3— open I View of Health Workers - Indicators: • 20 out of 22 health workers considered that health and hygiene habits had been influenced by the health promotioll activities of the monks
- Ilool 5.14 — closed I • Comments fronl health workers reveal some furtller perspective in the influence or not of the religious practitioners’ healtil promotion role on the community people: =~ Sometimes people still wait too long before coming to hospital. it is not only the remote and uneducated, it happens with town and educated people too. The
belief is so strong - ~ Health personnel have been giving these messages for many years but religious practitioners llave only recently been introduced to this. It is a result of everyones contribution. If tile lleaIth worker is the oniy person giving the health messages it will
- not work. If the Gomchen is trained, he is trusted by the people and the people will listen, even though tile message may have been given 100 times by the health worker ~ RHP has brought changes in personal and environmental hygiene ITool 5.5/lool 5 site proll les — open~
Conclusions c2: Influence of the relk~iouscommunity and/or the community-based religious practitioners on the health seeking and hygiene practices of the community
No one is denyitig that there has been all influence on tile H+H habits of the community people. The message is clear. that tile changes and improvements are a result of everyone’s effort. Neither is anyone denying that tile role of tile religious practitioners is one that has a
RHP Report 2 Key Questions 40 RHP Evaluation Report — Key Questions particular influence on communities because ofthe trust and respect accorded to religious practitioners in Bhutan.
Though the community response to questions ontheir H+H practice indicated that good practice is the norm this is the most likely response since it would be difficult for anyone to admit to bad habits. It is fairly certain that awareness has been raised, ifhabits not completely changed. Ifthis is the case then reminders and reinforcement ofthe main messages will eventuallyturn awareness into practice and habit.
Note: Qu 6.3 was re-worded — Ifyou do practise good H+H habits were did you learn these habits?
Analysis B: Effective Performance ofReligious Communities as Health Promoters in their
Communities - Key question c2 = POSITIVE IMPACT
Conditional: Changes have to become habit, eg. waste pit use, thenthe influence is - complete.
Sunday, a day forwashing and bathing for monks at the Dechenphodrang Monastic School
41 RHP Report 2 KeyQuestions RHP Eva Iuation Report Key Questions
Key Question c3. - Behavioural changes in the community Are there any added advantages of the religious community and/or community-based religious practitioners promoting health?
View of Community People Indicators: • The community people made the following comments: ~ Some cai~accept and understand advice from nlonks while others will accept from the
ilealth workers. Some will only have contact with one or the other — so this way all get the health messages ~ Much improved health in tile village after RHP. • 5-6 children used to die eacll year fronl diarrlloea,. now there are none • Vasectonly and family planning advice was done
• STD/AIDS messages given - • Suggestiolls wilich give even n~oreadded advantage; ~ Those religious practitioners who have not been trained may continue to conduct the puja and delay the medical treatnlellt. It would help if those people were trained ~ lithe health worker could visit the n~orerelilote places where the religious lractitioners still find it difficult this would he of more benefit ~ [he powa cannot really communicate. An able comnlunicator is the one who should be trained • Problems embedded in tradition yet to he overcome: ~ Village people see sollletillles that even with an injection or operation you do not get
better — you may die - alld they are scared ~ The powa misleads and tile people have to do as they are told. Soille people have died
- because they haven’t gone for medical treatment -
- Fool 6)))—open I Conclusions c3: Added advantages of the religious community and/or community-based religious practitioners promoting health
The main advantage is tile channel for communication that the religious practitioners have with the local comnlullity as an alternative and direct means of promoting health messages. Most people interviewed could identify 00 problems ill tile role of religious practitioners as lleaith promoters. To tile conlmunity people tile benefits can already be seen ill better living conditions and less sickiless. -
The issue was raised of targeting of those who can bring more benefit the local comillunities. Tilis includes those religious practitioners ill iiioi-e relllote locations where cilange is more gradual or perhaps more resisted, or where access to ilealth services is more difficult~and to identify participants for training who are most able as communicators. It has also been suggested elsewilere that tilose who are interested and influential should be selected br training. Ellis will be raised again in the Future Strategies.
Analysis B: Effective Performance of’ Religious Communities as Health Promoters in their
Comnlunities -
Key question c3 = POSITIVE IMPACT Conditional: Greatest advantage ii traillitlg is targeted to give the greatest impact.
RI-IF Report 2 Ke Questions 42 RHP EvaIua~tionReport — Key Questions
Key Question c4. - Behavioural changes in the community Are there changes in the health seeking and hygiene practices of the religious community and/or community-based religious practitioners after RHP training workshops? -
View of Community People - - - -
Indicators: - - • 38 out of 40 community people feel tllat religious practitioners have good I-I+H habits; 3 people couldn’t comnlent on tile I-i+H practice of religious practitioners • 37 out of 40 feel that those good ilabits-mciude use of latrine (no open defecation), hand washillg before meals and after latrine, cleaner personal appearance and waste put in pits and bins; 3 people couldll’t comment 00 tile H+H practice of religious practitioners Fool 6.5—6 — closedI
• -The community people made tile following comments: - ~ The health workers taugilt the religious practitioners which has led to improvements
in 1-1+1-I habits - - - - - =~ Tile Gonlchens know from reading the books (FFL and HOI-l) aild from the RHP training. Then others can see from the example of those who are trained Fool 6.7 — openi
View of Health Workers : -
Indicators: - • All 25 healtil workers have fairly regular contact with religious practitioners • All 25 health workers have noticed changes in tile H+H practices of the religious-
practitioners - - - - [Fool 5.1—2/5.5 closed I • All 25 health workers llave noticed improvements in religious practitioners’ use of latrine (no open defecation). hand was.hillg before meals and after latrine, aild cleaner kitchens. • 23 out of 25 llealth workers Ilave noticed inlprovenlents in religious practitioners putting waste in pits or bins. 2 health workers have noticed 110 inlprovement in religious practitioners’ putting waste in pits or bins • 9 health workers feel there is an improvement in vaccination of monks. 16 health workers considered this not to be relevant either because they are vaccinated when they are small, before becoming monks or because the religious institution takes older, adult monks [See note belowl • 24 out of 25 healtll workers have noticed an increase in the number of religious practitioners seeking medical advice from llealth workers • 22 out of 24 healtil workers iCci that there is improved knowledge of STI)/AIDS by religious practitioners. 2 health workers feel there is no improvement ill tile knowledge of STD/AIDS by religious practitioners and one health worker couldn’t say yes or no.
[See separate sectioll Key Issue - STD/AIDS]
I tool 5.4/5.6 — closed I • The health workers made the following comnlents: ~ After RHP anims canle to tile BI—IU for treatment and they brush tilcir teetil. The allims and tile Lama give the advice to seek medical treatment when called for puja ~ RHP will improve tile sanitatioll and personal hygiene of the monks aild tiley are tile niaill contact with the conlllluflity who will listen to them. It is equally benefiting tile conlnlunity
~ RE-IP water taps and latrines have brought improvements - ~ RI-IP has illtrOdUce(l new knowledge and practice in use and construction of latrines. kilowledge of STD/AI l)S and early referral to hospital
43 RHP Report 2 Key Questions RHP Evaluation Report — Key Questions
Those Jakri who have beell trained give better H+H messages ~ Great change in seeking treatment in times of emergency even with tile sick in the Dratsang. They used to do puja and bring gelongs late for medical advice [Fool 57— openI
Conclusions c4: Changes in the health seeking and hygiene practices of the religious community and/or community-based religious practitioners after RHP training workshops
Community people see changes ill tile H+H practices of religious practitioners as coming from other sources apart from RHP including advice from Je Kilenpo and Dasho Dzongdas. fronl sector meetings in the Dzongkhag. from the healtil workers, from tile Lanl and tile Rimpocile. and from the Buddilist teachings of the virtues of happiness [Tool 6.71.
Healtil workers see inlprovements in: hand washing (now routine), waste disposal (before they used to throw down tile slope), health (scabies used to be a problem — now it is completely cut dowil), personal hygiene (they maintain the bedding), vaccinations (now almost all are covered). The health workers also mentioned that routine visits or ORC are now provided to religious institutions. The problem of providing health advice to those in meditation seems to have been solved by training gelongs as VHW in some institutions.
Of’ahi tile H+H ilabits listed, waste disposal is tile only one in which several health workers feel there has been 110 improvement and, as was noted in Key Question b3, is one ilabit to wilicil religious practitioners make 110 reference in their wide ranging comments. Tllis may he because there is still a lack of awareness of this as a serious H+H problem. 1-lowever evidence in the environment througilout Bhutan suggests that this llas yet to become a habit generally. Comments Oil use of waste pits: ~‘Wehave been encouraging this but still they are
IlOt doing this. Some use it, most still don’t - 40% use tile waste pit’.
Note: All the colllrnunity based religious practitiollers indicated tllat vaccinations are given. 2 religious illstitutions with younger anims and monks indicated tilat vaccinations are given. If tiliS is considered a critical issue it is suggested that a more focussed survey be undertaken. One problem with tile findings in tilis evaluation are tilat tile PC~S0ll5questiolled i~iay110t have been the person who would know this illiorillatioll.
Analysis A: Positive Behavioural Challges Ill Religious (‘onlmunities Key questioll c4 = POSITIVE IMPACT Conditiollal: Changes becoming Ilahit.
RI-IF Repott 2 Key Questions 44 RHP Evaluation Report — Key Questions
Key Question dl. - Health workers’ views Rate the effectiveness of the religious community and community-based religious practitioners as promoters of health messages.
View ofHealth Workers -
Indicators: - - - - • Tile results of the Healtil Knowledge Test indicate a good level of health knowledge for both RHP trained and untrained religious practitioners
[l’ool 2 — test] • ii out of 23 health workers rated religious practitioners’ health knowledge as FAIR • 12 out of 23 llealth workers rated religious practitioners’ health knowledge as GOOD • 8 out of 23 health workers rated religious practitioners’ as FAIR comnlunicators • 14 out of 23 health workers rated religious practitioners’ as GOOD commullicators • I out of 23 health workers rated religious practitiOilerS’ as VERY GOOD comnlunicators
- 1511—12 — closed] • The healtil workers made tile following comments: =~ People have special trust in the monks; with HA they will make excuses that they are
too busy -
~ Viilagers~behievewilat the monks-say - ‘ - - -~ ---~-. ~ Some Gonichens are very good at giving health messages
~ It achieves the goal of health services by reaciling the community directly — the
messages must be sinlple - ~ There is a big role tile religious practitioners can play if tiley have tile knowledge and
- use it in the right way
~ We can reach the maximum populatioll Witil ilelp from the religious- conimuility — indirectly or directly they and the community will benefit ~ Ihe religious practitioners nlake the health workers job easier ~ For the person givillg the messages they have to give tile correct messages not tile
wrong messages -
-- [Fool 5 o) — open I Conclusions dl: Effectiveness of the religious community and community-based religious practitioners as promoters of health messages
[lie health workers consider religious practitioners to he effective promoters of health messages. Ol’those religious practitioners who arc actively promoting health and have been trained the health workers considered their ilealtll knowledge and Commullication skills to he
b’air or good. -- -
The reasons given for the effectiveness of the religious practitioners as health promoters are:
Trust from the community Communication skills Simple messages Health knowledge Direct contact with the community
45 RHP Report 2 Key Questions RHP Evaluation Report — Key Questions
Some health workers expressed a concern that the role might be taken too far by some religious practitioners and wrong messages given. The health workers suggested that the safeguards against this happening are a) to give regular refresher courses since the religious practitioners might forget the messages b) use some selection criteria for participation in workshops for example the trust from thl community and the interest ofthe religious practitioner in the training, and c) clarify the extent ofthe role with the religious practitioners. - These points will be raised again in Future Strategies.
Analysis B: Effective Performance ofReligious Communities as Health Promoters in theii Communities Key question dl = POSITIVE IMPACT Conditional: Effectiveness is dependant on religious practitioners’ knowledge and communication skills, interest and enthusiasm.
Toilet for monks atTsirang Rabdey
RHP Report 2 Key Questions 46 RHP Evaluation Report — Key Questions
Key Question d2. - Health workers’ views Do health workers view the religious community and community-based religious practitioners as competitors or complementary?
View of Health Workers
Indicators: - • 23 out of 23 health workers appreciate the contribution ofreligious practitioners to -health matters in their community I-Fool Slit — closedI • The health workers made tlle following comments: =~ There used to be a barrier between the religious community and the health workers. Now the religious people are advising people to come to the BHU. The RHP workshop has changed the attitude. We cannot say don’t do puja
=~ It is a result of tile involvement of tile two sectors — religion and health. Tile community always goes to the religious practitioner first. We see big improvements now they are communicating H+H messages ~ When the BHU was newly established some villagers were not happy, especially with vasectomy. Lam and the Gup attended a community meeting to discuss the problems =~ The VHW, tile Gup and the Gomchen have taught the villagers to improve H+H in the community
[Fool57 — openI Conclusions d2: Health workers view the religious community and community-based religious practitioners as complementary l-lealth workers are working in partnership with the religious practitiollers to convey health messages to tile community people. VHWs and staffat BHU’s who are working in the conlmunity are generally working very directly with the religious practitioners, especially in cases where the llealth workers have also participated in or facilitated RHP worksllops. Both llealth workers and religious practitiollers are key people within their community. In some cases a Gomchen, monk. Tsip. Jakri, Gup or Tsokpa was also RI—IP trained, VHW trained or both and in several cases tile VI-IW was also RHP trained.
The majority of the Health Assistants interviewed showed a high level of commitment to RI-IP linked to their level of involvement in the project, which was commendable. Tile evaluator observed that religious practitioners (including monks. anims, Jakri, GonlcIlen, Powa. Pandit and Tsip) and Ilealtll workers (including VHWs, BHWs, ANMs, HAs and DI-ISO) in some districts were particularly active and a strong relationship had been established between tile religious community and the health staff
Analysis B: Effective Performance of Religious Communities as 1-lealtil Promoters in their Coni munities
Key question d2 = POSITIVE IMPACT Conditional: none
47 RHP Report 2 Key Questions RHP Evaluation Report— Key Questions
Key Question d3. - Health workers’ views Has there been an increased number of patients from the community referred by the religious community and/or community-based religious practitioners following RHP workshops? -
View of Health Workers - Indicators: • 19 out of 23 Ilealtil workers indicated that there has been an increase ill the number of patients, of whonl 18 considered this to be in part a result of the religious practitioners’ role as health promoters. The four health workers WilO ilave seen a decrease in the nulllber of patients explained tilat this is due to easier access to another facility eg. a new BHU construction. ITool SIS-lô - closedi
Conclusions d3: An increased number of patients from the community are referred by the religious community and/or-community-based religious practitioners following RHP workshops
As has been seen in earlier comments there is an increase in tile number of community people seeking lleaitil advice and this could in part be attributed to tile impact of the RIT-IP training. It could also be attributed to the other factors tilat ilave persuaded people to seek medical advice: Acccssibility to BHU or ilospital Impact of education and development gellerally Community awareness of importance of 1-1+1-I 1-1+1-I messages commullicated from various sources including health workers and religious practitioners
Key Question al considered the issue of early referral, which could be further investigated.
Anal~”sisB: Effective Performance of Religious Conlmunities as Health Promoters in their Commullities
Key question d3 = POSITIVE IMPACT Coilditional: Early referral is tile key factor
RHP Report 2 Key Questions 48 RHP Evaluation Report — Key Questions
Key Question el / e2. - Effectiveness of training workshops What knowledge has been retained by religious persons who attended RHP training workshops? What is the knowledge of religious persons who have not been trained?
Indicators: • The most popular and least popular topics in the health knowledge test
Trained religious Untrained religious practitioners practitioners
Most popular topic Prevention of Personal Hygiene Diarrhoea! Diseases and Sanitation
Least popular topic Immunisation Immunisation -
• Personal Hygiene and Sanitation topic produced the highest scores for both trained and untrained religious practitioners • Immunisation topic produced the lowest scores for both trained and untrained religious practitioners
• The questions which produced the best scores are: - 2. 16 What is tile best source of food and drink for a baby in its first few months of life? 2.21 What does imnlunisation do for children? Re-worded question led to answer
2.1 What is diarrhoea? - Re-worded question led to answer 2.8 What are tile nlain food preparation practices that prevent illnesses?
General — want’ ~iim’ti-’ers • ftc questions which produced the worst scores are: 2.25 Pregnant women should go to the Ilospital or Bi-Ili for immunisation against one disease especially. Wilich disease? On/v one correct (I/1SoCI’ /)Ossib/L’ 2. 1 7 What are tile advantages o-f hreastmiik over formula or cot-v’s milk?
- One reason give — two required 2.2 Why is diarrhoea of such concern? Spec~fIcreason not given • Don’t know responses: Trained religious practitioners did not know the answer to 4% of the questions asked Ulltrained religious practitioners did not know the answer to 8% of the questions asked
• Wrong answers: - [rained religious practitioners gave tile wrong answer to 3% of the questions asked Untrained religious practitioners gave tile wrong answer to 4% of the questions asked
• Partly correct answers: - Irained religious practitioners gave partly correct answers to 22% of tile questions asked Untrained religious practitioners gave partly correct answers to 27% otthe-questions
asked - • Correct answers: [rained religious practitioners gave tile correct answer to 71% of the questions asked Untrained religious practitioners gave the correct answer to 61% of the questions asked • Untrained scores ranged hetweell 62% to 100% with an overall average score of 84% Trained scores ranged between 75% to 98% with an overall average score of 89%
I lool 2 — test I
49 RHP Report2 Key Questions RHP Evaluation Report — Key Questions
The alternative responses given to questions in the Health Knowledge Test are analysed in the RHP Evaluation Analysis [Tool 2 Alternative Responsesi. For example, responses given for causes of diarrhoea included:
~ playing in cold water - -
~- sitting on wet ground ~ keeping the children cold
Tile tally for each answer is also given, silowing the most frequent and least frequent responses for each answer. For example. again in response to tile question on the causes of diarrhoea only one person mentioned infection as a cause of diarrhoea, whereas 22 people responded that dirty food is the cause of diarrhoea and 14 people responded that tile reason is dirty hands or dirty water. I Fool 2 alternative responses I Conclusions ci: Knowledge retained by religious persons who attended RHP training workshops e2: Knowledge ofreligious persons who have not been trained
Tile test results between trained and untrained religious practitioners are quite closely - matched. More untrained religious practitioners said they did not know tile answer and more trained religious practitioners gave tile correct answer. [he range of scores is wider for Untrailled than for trained religious practitioners.
Since there is no measure of tile level of knowledge the religious practitioners had before training we might assume that tile untrained religious practitioners give SOflIC indication of the pre-RHP training levels of knowledge an~~i~greligious practitioners. We can only then conclude tllat eitller a) a lot of knowledge was acquired in the Rl-lP training and some is now lost (therefbre
there is a need/br refresher courses) - but still the trained religious practitioners have more knowledge than those who are untrained, or h) little new knowledge was gained ill the RFIP training ~1hegeneral consensus is likely to he in favour of (a). wilich therefore supports tile case for refresher training, ii’ this hypothesis is accepted.
The untrained religious practitioners showed a reasonable level of health knowledge. Some of the ilealtll knowledge questiolls related to general H+i-i practice, such as qu.2.7 When is it 1-nost important to wash the hands?. Other questions required actual llealth knowledge. such as qu.2. 1 0 What is a water—borne il/sects-c that could be prevented t-i’ith helter hygiene/clean waler?. Some religious practitiollers who have not received RHP training have either been trained as VI-IW or have been informed of some of the health messages through others in their conlmunity who have been RHP trained. It is pleasing to note that tile general level of’ llealtll knowledge is quite reasonable hut training would improve tllis still further and, perhaps more importantly, would give tile religious pi’actitioners more confidence in their level of llealth knowledge
The analysis of the Healtil Knowledge Test responses and the i--Iealth Kilowledge Test itself may be useful for monitoring and evaluation in the future. It should be noted that some questions needed to be re-worded ~orclearer understanding. Ihis will he raised again in Future Strategies.
RI-IP Report 2 Key Questions 50 RI-IP Evaluation Report — Key Questions
Note: questions had different weighting according to whether there was one and only one correct answer or whether there were several possible answers; whether one answer gave a correct score or whether at least two answers had to be given; and whetherthe questions were general knowledge or technical health knowledge. This would account for some variation in scores between questions but was not taken into account in the design ofthe scoring system.
Analysis A: Positive Behavioural Changes in Religious Communities Key question el/ e2 POSITIVE IMPACT Conditional: Provision oftraining courses, reference books and refresher training
Analysis B: Effective Performance of Religious Communities as Health Promoters in their Communities
Key question el / e2 POSITIVE IMPACT - Conditional: Selection ofparticipants for training who are interested to participate and have contact with the community people.
Little Monks at a Participatory Rapid Appraisal (PRA) session at Dechenphodrang Monastic School
51 RI-IP Report 2 Key Questions RHP Evaluation Report — Key Questions
Key Question e3. - Effectiveness of training workshops What additional areas of health would the religious community and/or community- based religious practitioners like to learn about in the training workshop to enhance
their role as health promoters? - -
View of Religious Practitioners Indicators: • The religious practitioners made the following comments: ~ Training in giving tile same 9 medicines given by the VHW
=~ No new topics — what has been received is good ~ First Aid teaching would be helpful ~ Refresher of wilat was taught last year and has been forgotten ~ i-low is malaria and typhoid caused and how sllould we treat diarriloea?
IFool 41 21X II — open]
Helping to find a way around the astrology chart when something conflicts with going for medical advice. For example, if the person is not to go East and the BHU is East. Finding a way around this is important. Comment from a Gomchen
View of Health Workers Indicators: • Topics whicil the health workers feel are understood by the religious practitioners and the community people: • Personal health education
• Family planning — 100 % take up in some areas • Topics which the health workers feel are not understood by the religious practitioners and community people and WilicIl silould he included in RHP workshops:
Tragically a 2 year old child died the night we arrived at one location. Tile sickness was pneumonia but tile parents didn’t know tile fatal synlptoms of ARI. The child had been sick for nine days before being brougilt to the BHU. Tile I--Iealth Assistant worked through the night for 12 hours to try to save the child but could do Ilothing ill tile did.
Early referral is’ould have saved the child’s life.
• Diagnosis of signs and symptoms of illnesses for timely referral eg. ARI • l~amilyplanning • Personal hygiene • Environmental sanitation and safe water • Basic medicines • Conlplications of Diarrhoea • Training for mothers • Nutrition • First Aid • The health workers made the following additional comnlents:
RI-IP Report 2 Key Questions 52 RI-IP Evaluation Report — Key Questions
=~‘ Early referral:— still some people delay when there is no-one to advise or because of their belief ~ There is still a problem of single mothers who are too shy to come for anti natal check up. Tile village leaders are following up ~ Tile religious practitioners still Ileed health and personal hygiene education ~ Teach tile simplest things • Keeping the surroundings clean • Make a paved path • Latrine collstruction
- • Personal hygiene
Ilool ~7 — opei I Conclusions e3: Additional areas of health the religious community and/or community-based religious practitioners would like to learn about in the training workshop to enhance their role as health promoters
The religious practitioners are satisfied with the RHP training topics covered previously and tile consensus view is to leave the choice of topics to tile proféssiollals, the health workers, for future training programmes. Some suggestions have been proposed by tile health workers as given above. This is further considered in Future Strategies.
Analysis B: Effective Perfornlance ol Religious Communities as l-lealth Promoters in their
Conlmunities -
Key question e3 = POSITIVE IMPACT Conditional: Review training needs for each training depending on participant and conlnlunity 1-1+1-1 needs. based on advice from health workers.
Several religious practitioners simply said “Let the healtil workers ideiltify what is needed. \\-hatever they think is most necessary”.
53 RHP Report 2 Key Questions
/ RHP Evaluation Report — Key Questions
Key Question e4. - Effectiveness of training workshops How can training workshops be further improved?
View ofReligious Practitioners Indicators: • Tile religious practitioners made tile following comnlents: ~ Monks as workshop facilitators ~ Train influential and educated religious practitioners who can run a workshop in their village =~‘ By seeing we learn 70% so the n~essageswill be leariled quickly with videos and photos. Some people don’t understand the lecture metilod
- - - [Fool 41 3/Tool 5/12 open
View of Health Workers - - - Indicators: • Tile health workers made the following comments: =~ Religious practitioners need more follow up and guidance ~ Train people in their OWIl community
~ Some people forget - some are not trained - some have retired. A regular programme of workshops is needed
~ Workshops once a year with religious practitioners as facilitators - - - ~ Some villages are less clean. Call those people specifically
=~‘ If workshops are given for two villages with people attending from some households tilis would be helpful
~ Video is easier for people to understand than lecture — everyone will come!
One Jakri commented: Train some younger people. I have been trained twice and I am 74 years old. ~ ~ [Fool 5 Site Proliles - open]
Conclusions - e4: How training workshops can be further improved
A number of suggestions have been put forward by religious practitioners and healtil workers whicil support many of the findings in the earlier analysis. Consideratioll Ileeds to be given to participants, content, location, facilitators. methodology, logistics including plailning, nlonitorillg and follow up. Needs analysis may be useful to clarify which improvements sllould be made. lhe COnSenSUS definitely supports the continuation of tile RHP training progran~mebut there is scope for review.
Analysis B: Effective Performance of Religious Commullities as Health Promoters in their CoIllIllunitieS Key question e4 = POSITIVE IMPACT Conditional: Review tile RUP training programme nlodel
People are interested because there is good food and you can gain more knowledge Comment from a gelong
RHP Report 2 Key Questions 54 RFIP Evaluation Report — Key Questions
Key Issue - Effectiveness of Project Management - How can RHP project management be farther improved?
View of the Religious Practitioners
Indicators: - • The following suggestions were put forward by tile religious practitioners: ~ Annual gathering of Dungchens and focal points to discuss and share ideasotherwise the objectives will be abandoned ~ Focal points could assist with the workshops in other Dzongkhags. This would give
encouragenlent and they would prepare carefully. There would be opportunity for -
greater sharing of id~as - ~ Translation of Guidelines illto Dzongkha would be useful ~ Better planning eg. coordination of dates for workshops and advanced information for budgeting and accounts ~ More monks should have the opportunity to attend workshops in the future
~ More funding for more workshops - ~ Workshops silouid be held in locations wllich are easy to access for the participants ~ Dratsang Lhentsog silould call a nleeting of all the religious practitioners and people from the shedras wilo ilaveillfluence. Then they could discuss ideas for the future of
RHP - - - , -
[tool 414 — open I
View of the DHSO’s - Indicators: • ihe following suggestions were put forward by the DHSO’s: ~ At Dzongkhag level there should be a focal person. Train some monks with close monitoring from Thimphu and they can take responsibility to conduct workshops on a regular basis ~ Training of tsips needs to he intensified. Better to go into the field for training, for exanlple covering two hiocks. If we go to tile religious practitioners we do not miss them. l-lere (in the Dzongkhag I-IQ) only a few will come. ~ Coordination should have been decentralised otherwise there are problenls of executing the workshops on time, waiting for the approval for everyone to be ready. ~ Decentralise and hand over to trained trainers witil support from Dratsang Lhentsog +
hooks and videos - ~ Monitoring can be done at village level if you sit Witil tile community and ilear their
problems - ~ Proper guidelines need to he developed ~ Iitile funding is given we can Illohilise down to the village level ~ There siloulci he timely and regular follow up fronl the centre. II~lQ oPeil I
Conclusions - How RHP project management can he further improved
the main criticisms of managellient of the RHP programme are those of which tile project
nlanagement is well aware A’o mon/luring and eva/na/ion - No re/resher COUrSeS A~o/dcccflhl’(lliSCd
55 RHP Report 2 Key Questions
/ - RHP Evaluation Report — Key Questions
Tile religious practitioners and DHSO, wllile taking the opportunity to provide constructive critical comment on the RHP project also acknowledge the achievements. One DHSO states tllat RHP is not going as well as it should and refers to tile above points of criticisnl. However this is not negative since it is not suggesting tilat RHP is moving in tile wrong direction or achieving nothing. Rather tile comments from all tile respondents refer to the need to continue the project, tilat more can be achieved, and that in the light of experience it is perhaps time to review arid improve some aspects of the project.
It is the task of the project management to now review the situation and address these particular weaknesses. The ideas that have arisen from the evaluation are drawn together in Future Strategies and Guidelines for Future Activities which tile project manageillent siloUld seek to action.
Management Analysis Key Issue = POSITIVE IMPACT Conditional: Review the managenlent of the RHP project:- re-define roles and responsibilities of all stakellolders to village level
RHP is achieving the purpose of educating the religious practitioners and sensitising them. Unsure whether the message is getting to the villagers Comments train a DI-ISO
Rl-IP Report 2 Key Questions 56 RHP Evaluation Report — Key Questions
Key Issue - STD/AIDS Issues relating to STD/AIDS knowledge among religious practitioners
The evaluator singled out STD/AIDS as, of all the H+H topics, it emerged as being the nlost sensitive for the religious cOmtllUflity to discuss. The Health Division advises not to single out this topic. However the sellsitivity of the subject with institution-based religious practitioners and the support given by Je Khenpo to this issue suggests that it should be acknowledged as part of tile evaluation process.
The question (3.8.4, 7.2.4 and 5.6.3 to religious practitioners and health workers) was re- worded from tile original “What do you do to stay ilealthy — STD/AIDS prevention” which drew the response that this is not an issue for celibate religious practitioners. The re-worded cl~lestion“What knowledge of STD/AIDS do you have?” drew more useful responses as given below. View of Religious Practitioners Indicators: • The religious practitioners were asked wilether tlley had knowledge of STD/AIDS:
Knowledge of RHP trained Untrained Total STD/AIDS
Yes - 16(42%) 13 (34%) 29(76%)
No 4(11%) 5(13%) 9(24%)
2 — commented not applicable to religious practitioners
[loot 354/Foot 724 — closed] • Further comnlents:
- It is a fanlily problem. Monks wont get it
- Many of the monks are so small it is not relevant to them
- Since monks don’t marry they doll’t Ilave to take actioll
- I-IlV can he transmitted from shaving heads
- Have heard of AIDS and know there is no treatment for AIDS but that you have to use condoms
- I know the problems of STD/AIDS aild say to people “A person might look clean hut you can’t tell if they Ilave STD/AIDS. You silouidn t make easy relationships” Some
- people don’t want to know
- Not an approved topic for the aninls
[loot 3 Site I’roli es— openI View of Health Workers Indicators: • 22 out of 24 health workers feel that tllere is improved knowledge of STD/AIDS by religious practitioners. 2 health workers feel there is 110 improvement in the knowledge of STD/AIDS by religious practitioners and one health worker couldn’t say yes or no.
Iloot 56 — closed I • Further comments:
- You shouldn’t feel shy about discussing the topic. People should k-iio~wabout it and know the dangers
57 RHP Report 2 Key Questions RHP Evaluation Report — Key Questions
- After the promotion of STD/A1DS issues even the monks know this now if they have attended training workshops
- Messages Ilave been communicated through BBS. Tile monks are not supposed to listen to tile radio
- The monks ilave a little knowledge and they are asking about prevention
- STD/AIDS was not included in the RHP training hut the Gomchens need to be educated on this topic - - - [tool 5 — open]
Conclusions Issues relating to STD/AIDS knowledge among religious practitioners
There is little difference in knowledge of STD/AIDS hetween tile RHP trained and the untrained relFgiou~practitioners whicil suggests tilat this message is being comnlunicated through other cilannels, but one quarter of those interviewed llad no knowledge of STD/AIDS according to their respoilse.
Is lilis a topic which needs to be approached in a different way for the religious practitioners, particularly for tile anims? Should representatives from the religious community and Health Division review the issue?
STD/AIDS
Key Issue = POSITIVE IMPACT Conditional: The sensitivity of the subject needs to be considered in future training programmes atld further consideration given to overcoming tile taboo.
RI-IP Report 2 Key Questions 58 RHP Evaluation Report - Conclusions
Main Conclusions
Health workers had always seen the problem from their perspective. A new scenario is there even in the far flung places. Also the practice in the religious community has improved. Comments from a DHSO
To sunlmarise, the main conclusions tronl the Religion and Health Project Evaluation are:
Behavioural Changes in Health and Hygiene Practise . -
(religious community and wider community): -
1 . Religious practitioners have improved their ilealth and ilygiene practices.
2. Religious practitioners have been eliCctive in conlnlurncating basic health and hygiene
messages to tile community people. - - -
3. Community people have improved their health and hygiene practices. -
Religious Practitioners as Health Promoters:
4. Religious practitioners and comnlunity people practice both medicine and puja at times of sickness in the fanlily. ihe common practice varies according to tile sickness:
• Serious illnesses are referred to tile BI-IU or hospital immediately • For less serious illnesses a puja is conducted and tilen tile person is taken for medical advice ifthere is no illlprovement. • Spiritual problenls are treated by puja. • Sonle religious beliefs still present an obstacle between puja and medical treatment. For exanlple, the direction a person silould take. It is not possible to establish Ironi the evaluation what would constitute a serious illness. The evaluation was not designed to find out any more detail about what would collstitute a serious illness, a less serious illness or a spiritual problem but this topiccould be further explored. 5. Religious practitioners and health workers believe there is more that can be done in mobilising the religious practitioners as promoters of good health and hygiene habits in
tile commwlity. - - • More training and mobilisation 91 religious practitioners. • More responsibilities for those who are willing. eg. the VHW role. • More of tile same messages already being given.
Provision and Maintenance ofWater and Sanitation Facilities: 6. RI-IP improved waler and sanitation facilities contribute to improved health and hygiene practices for religious practitioliers and comnlUnity people.
• 1-1+1-I awareness and trailling WitIloUt improved facilities is frustrating.
59 RHP Report 3 Future Strategies and Activities RHP Evaluation Report - Conclusions
• The standard of facilities at religious institutions is generally less than satisfactory. Either there have been few inlprovements or those improvements that have been made are not functioning as they should. • Tile ratio of population to facilities is not adequate. • ‘File rush to use tile limited facilities at certain times of the day eg. before morning prayers, is not practical given the limited facilities. It is often the younger monks who are unable to access tile facilities and who may consequently receive punishment. 7. Water and sanitation facilities are properly maintained in most sites visited, where this is within the means of the religious practitioners or Dzongkhag maintenance people.
• Some religious practitioners are trained ill maintenance and they have some basic tools. Some religious institutions ilave a deposit fund, the interest from which is used
to pay for on-going maintenance costs. - • At some sites tile facility is not functioning and tile religious practitioners do not know what action to take. • Tile latrine and water supply facilities give tile most maintenance problems. 8. Water and sanitation facilities are kept clean in most sites visited: • The younger nlonks tend to be the worst offenders with latrine facilities, which suggests additional input targeted at the younger age group would he beneficial, eg. children’s books. Punishment is not necessarily helpful but is sometimes used. 9. FIle H+H habit least well practised by the religious community and community people, is waste disposal. There llas been an improvement in construction of waste pits but these are Ilot always used.
Effectiveness of RHP Training:
10. RI-IP training workshops and tile associated hooks Facts for Life and Health in our i-lands have been very effective in raising tile awareness and level of knowledge of religious
practitioners to key H+i-l messages: - • The training programme should continue. • There are many religious practitioners wilo Ilave not yet been trailled. • Those who ilave been trained require refresiler courses. • Future training progran~mesnlust include a component on maintenance of water and sallitation facilities • Future trailling programmes sllould target key people as participants. For example: • those from the most needy conlnlunities • those wilo are interested and enthusiastic • those who are influential witilin tile conimunity
• tilose who are least educated. - • Other training strategies could be considered, for example: greater decentralisation • use more religious practitioners as facilitators • include comnlullity people as participants as well as religious practitioners • training of trainers. • (iuidelineS~shouldhe produced for workshop facilitators. • ftc health publications should be distributed in Nepali in same districts.
RI-IP Report 3 Future Strategies and-Activities ~fiO RHP Evaluation Report - Conclusions
Monitoring and Evaluation:
ii. Monitoring and evaluation of RHP has been seriously neglected to date.
• M&E has been included in RHP documentation since the Concept Paper in 1 990 • Reports on worksilops are submitted to RHP. 1—low are these used?
• - M&E can be undertaken at central, district and village level • A M&E strategy and plan of action needs to be developed and implenlented STD/Aids as an issue for the Religion and Health Project:
1 2. Ulere is some knowledge of STD/AIDS \Vitilin the religious community hut for many it remains a sensitive subject or is considered not to he relevant to religious practitioners. • STD/Aids is likely to be a less sensitive issue for community based religious practiti oilers. • STD/Aids sllouid not he sillgledl out as separate issue, but ways to include tile topic in H+I-1 training for religious practitioners needs to he reviewed. Effectiveness of Project Management:
13. Project managemellt is satisfactory hut there are sonic aspects of management that could be reviewed: • I)ecentralisation of roles and responsibilities of all stakeholders to village level. • management at district level • nlonitoring at village level and • regular follow up I ronl tile centre • Monitoring and evaluation needs to he reviewed and followed up
1 4. Tile partnership between Dratsang Lilentsog and l-Iealth Services. witll funding assistance from UNICEF. is working well in convcvillg health and ilygiene messages for tile benefit and well being of the citizens ofBhutan.
ftc Reiigion and i--leaith Project ilas contributed to improvemeilts in health and ilygiene pntctices throughout comniunilies in Bhutan. By conimunicating health and hygiene messages to community people when the religioLls practitioners visit people in tileir ilolTieS,
- they have influenced the healtil and ilygiene habits of comnlunit people ill Bhutan. There arc still some health and hygiene nlessages that are not ullderstood by the religious practitioners or community people and which need to contillue to be stressed. There are still some religious institutions and viilage communities where more can be done to provide access to sale water and iniproved sanitation Facilities.
Oilier agents of health promotion have also contributed to the overall achievements and it is not possible to state exactly which acilievenleilts are directly attributable to Ri-IP or to any other agelit of change in the health sector. More important than trying to make such distinctions, is to acknowledge that dilierent agents have different points of access and di lieretit comparative advantages.
- 61. RI IP Report 3 Future Strategies and Activities
7, Rl-lP Evaluation Report - Conclusions Comparative Advantage of Religious Practitioners as Health Promoters:
• The religious practitioners ilave a unique means by whicll to access people in all corners of the country. • Tile religious practitioners are trusted and highly respected by community people.
• Tile religious practitioners are usually the first people to be called to a house whell there -is a family sickness. • Tue Religion and Health training programme has increased the knowledge and awareness of religious practitioners to some key aspects of health and hygiene practice.
Recommendations Arising from tile main conclusions is tile following list of recommendations: Recommendatioll 1: Religious practitioners are the key to grass roots healtil and hygiene promotion and they should be encouraged to continue this role.
Reconlmendation 2: Not enough is known about wilat has been dolle and what is still ileeded through tile Religion and 1-leaith Project. -
• Data should he collated to show who has received software aild hardware inputs and the i)I’esellt condition of hardware inputs.
• Needs Analysis should then identify which locatiolls have not received software or
hardware inputs, to identify priority areas ------
Recommendation 3: All hardware inputsshould he accompanied hy software inputs. The software inputs should include training in hardware mailltellallce. -
Reconlnlendation 4: The Religion and Health Project is only one of a number of inputs. which has brougilt about improvenlents in I-I+H practice. Tile hardware and software inputs from all ageilts needs to he monitored and coordinated. for more effective coverage and
COOl munication of ilealth and ilygiene messages. -
Recommendation 5: A review of the Religion and I-lealtll Project Monitoring and Evaluation strategies should be undertaken, and a Monitoring aild EvaJuation plan of actioll should be
Silared with all stakeilolders. , - -
Reconlmendation 6: There is still a need to convey the importance of early referral. especially with cases sucil as ARI. Religious practitioners and cOlllnlullity people need to be taught the basic signs and symptoms and to refer early rather than delay. if in any doubt. \\tllere the sickness is more serious the religious practi~ioners~ndthe comnlullity people must know that medicille has to come first. before puja.
Reconlmendation 7: Further information should he sought on reasons for late referral including obstacles for the religious practitioner and ways around these obstacles~and conimullity people’s perceptions of serious and less serious sickness and spiritual problems.
RI-IP Report 3 Future Strategies and Activities 62 RI-IP Evaluation Report - Conclusions
Future Strategies and Activities: Suggestions for Project improvement
RI—IP Evaluation Objective 2: Develop future strategies by identifying areas of the project wilicll could be improved, particularly in the areas of project management, monitoring and training. -- - RHP Evaluation Obiective 3. Develop a guideline for future activities in tile areas of project management and partner coordination, monitoring and evaluation, and training.
Strategy I: Project Management and Partnership Post-Evaluation Review ofthe RHP Project by Stakeholders
a) Project Objectives - The RI-IP Project management team, in the light of tile evaluation, should review the Project Objectives. The same or revised Project Objectives can then he used as a reference point for all subsequent strategic considerations by the
managethent team. - -
h) Roles and Responsibilities - The roles and responsibilities of tile various stakehoiders
from central level, district level and village level should be reviewed: - • to ensure effective participation alld decision making • to enable further decentralisatioll and delegation of responsibility if appropriate, and
• to build and utilise capacities at the local le’vel. -
c) Decentralisation — Rl-lP evaluation responses indicated a demand For greater - decelltralisation of the coordination and mallagenlellt of the Religion and Health Project. Relating to roles alldi responsibilities (1 h. above), a strategy fot’ decentralisation of some aspects of tile project needs to be considered.
d) Priority Target Groups — The future software and ilardware. inputs need to target priority groups. Criterion for identilleatioll of target group~needs to he clarified.
e) Plan of Action — The Ri-IP managenlenttealll need to decide who is to take action and \Vilen the activities are to be implemented or actioned.
F) Networking between Communicators of I-1+H messages — ‘file RHP management teanl should consider strategies to facilitate a n~tworkbetween tile various agents colllmullicatillg H+l—l messages to tile community for more effective and consistent coverage. A mapping of the interconneë’tions between the various participants comnlunicating health nlessages to conlm-unity people is given below.
Project Management and Partnership: Post-Eva1u~tion,Reviewofthe RHP Project
- - by Stakeholders
Activity 1: Review Project Objectives -
i. Review the RHP Project Objectives and decide whether to amend or revise tile Project Objectives for tile next project period. ii. Ensure that the Project (!)hjectives, wbetIi~rtile same or revis~d.are used as the reference point whicil underpins all lurther decisions.
63 RHP Report 3 Future Strategies and Activities RHP Evaluation Report - Conclusions
Health Division - 4 —p.. Dratsang Lhentsog
~EF
Interconnections between the various participants communicating health messages to the community people ihe RHP evaluation shows that ileaitll messages are being communicated to tile conlnlunity people and there have been significant improvenlents in health and hygiene practices generally. Tile evaiuation indicates that SOO1C of this change is a result of tile RHP project hut that tilere are Otller agents of change.
The above diagram illustrates some of tile inputs and the interconnections, It shows RI-IP as having a direct and unique channel of illput to the comillUflity and it also shows the key role which i-lealth Division aild the healtll workers play in the whole scenario.
RI-IP Report 3 Future Strategies ~ndActivities 64 RHP Evaluation Report - Conclusions
Activity 2: Review Roles and Responsibilities i. Use a Stakeilolder Participation Matrix and Strengths, Weaknesses, Opportunities and Constraints Analysis (SWOC) to identify: • The present roles and responsibilities of each stakeholder group from central, district and village level • The strengtils and weaknesses of tile present structure at central, district and village level, and the opportunities and constraints which exist at each level. ii. Use a second Stakeholder Participation Matrix to define a new structure of roles and responsibilities for each stakehoider group. Examples (I) a Stakeholder Participation Matrix and (2) a SWOC Analysis Framework are given at the end of this report. - - iii. Ensure that new roles alld responsibilities and clarified and agreed with those to whom they apply. Link this activity to Activity Sii. Decentralisation
Activity 3: Define Priority Target Groups
i. The RHP management team should define t-he target groups for future software and- - hardware inputs by considering: • The Project Objectives (Activity I) • Baseline Data of inputs and comparison of all potential recipients of software and hardware (Activity 12) • A Needs Allalysis of community health and hygiene issues
ii. Link this activity to Activity 4. Plan of Action and Sii. Decentralisation. -
Activity 4: Draw up a Plan of Action
i. ‘Fhe Rl-lP management team should draw up a long term plan to cover the period from this evaluation to the next proposed evaluation (see Activity Ii) including targets for software and hardware inputs, and key stages in the strategic planning process.
A summary table of Activities and Ac/ion — -u’ho/i-vhen (Example 3) is given at the end of/his
r(’p()1’/ - ii. ftc implementers ol software and Ilardware programmes silould draw up a long term plan. coordinating their inputs to ensure tilat software and hardware inputs coincide.
Activity 5: Review opportunities for greater Decentralisation
I. Introduce and coordinate an Annual Meeting of stakeholders and focal points.
ii. The initial meeting sllouid he convelled to address the most significant outcomes of this evaluation and subsequent review ol the RI-IP. including discussion of: • Roles and Responsibilities of’each stakeholder group from central, district and village level (from Activity 2).
65 RHP Report 3 Future Strategies and Activities RFIP Evaluation Report - Conclusions
• Priority Target Groups and associated Needs Analysis (from Activity 3) • Decentralisation opportunities and implications
Activity 6: Facilitate a Network between Communicators of H+H Messages
i. Identi1~’the various agencies involved in communicating H+H messages to the
community. - ii. Facilitate a forum for networking between the agencies to exchange ideas and to ensure consistency and effective coverage. iii. Identify the comparative advantages ofdifferent agents. The comparative advantages of the religious practitioners as health promoters is given on p.62 ofthis report. iv. Use the comparative advantages to consider appropriate focuses for each agency.
Recently constructed teachers toilet-at Dechenphodrand Monastic School
RHP Report 3 Future Strategies andActivities 66 RI-IP Evaluation Report - Conclusions
Strategy 2. Monitoring and Evaluation Introduce a Monitoring and Evaluation Process a) Baseline data is required which describes tile software and hardware that has already been provided by UNICEF (see Summary Table of UNICEF Software and Hardware inputs for each Site, p.69) h) Additional data is also required on software and hardware inputs from other agents to
identify areas of duplication and neglect - c) Tools are required for on-going monitoring of software and hardware project inputs d) Workshop reports need to he presented ill a standardised format. Clarify the purpose of the reporting process. Can tile Worksllop Reports in tile correct format be used for on- going lllonitorillg purposes. ~15in I c above? e) Follow a cycle of: Plan -4 implement -4 Monitor 4 Review -4 Plan -4-4-4-4 f~ Roles and Responsibilities for all parts of the Monitoring and Evaluatioll process need to be agreed, involving stakeholders from central to village level. g) A second project evaluation will be required. dependant on project timeframes. Clear objectives should he deFined against which to measure impact or achievement. Do tile objectives need to be reviewed or do the existillg objectives still ibid as the focus or tile project?
Monitoring and Evaluation: Introduce a Monitoring and Evaluation Process
Activity 7: Baseline Data Collection i. Collate all available information as site profiles in a standardised format, or as a database ii. Conduct a simple survey for specific data not already available
Activity 8: Tools for on-going monitoring of Software and 1-lardware
i. Design ~omc tools br on—going llbOflitorillg by first considering tile following questions:
Who requires the information? - - • UNICEF
• Dratsang Lhentsog - • l-lealth Division • Others For what purpose is tile infol’nlatiOn required / I-low will tile illformation he used? • Future funding • Future training progranlnles • Success of’ past training programmes (impact)
• Future hardware inputs • Maintenance support for hardware inputs
67 RP~PReport 3 Future Strategies and Activities RHP Evaluation Report - Conclusions
• Other Who can provide tile information?
-• - Central level - Dratsang Lllentsog / Health Division / UNICEF
• District level - Dratsangs I Health workers -
• Village level - community-based practitioners / VHWs /community people What information is required? ii. Design a simple process of data collection, wllich is easy to analyse and which gives tile specific information required. iii. Decide who is responsible for data collection. allalysis and feedback.
Activity 9: Use of Workshop Reports
i. Review the purpose of workshop reports. - - • Who is the information for? • How is the information used?
• Is tile infornlation- received, the information which is required? ii. Design a simple workslbop reporting format and introduce into future workshop programmes iv. Decide who should receive the completed workshop reports, and how the information is to he disseminated or collated, Is some of the data relevant for on-going monitoring (linked to Activity 8.ii above)? An Example (4) of a Monitoring Frameworkfor RHP Workshops is given at the end of/his report.
Activity 10: Roles and Responsibilities for Monitoring & Evaluation i. Use a Stakeholder Participation Matrix (see Example I at the end of/his report) to allocate roles respoilsibilities for all aspects of the process of monitoring and evaluation. The matrix should be modified to focus only on M&E roles and responsibilities. ii. Complete one participation matrix to represent tile current roles and responsibilities and then complete as second matrix to show the new roles and responsibilities, delegating out to the district and village levels as appropriate.
Activity Ii: Planning for Evaluation ‘ - i. Review the present project objectives and agree within the management teatll on whether tile present objectives will need to he modified as objectives to be measured in the next evaluation (from Activity 1). ii. Build the next scheduled evaluation into the project framework (see Activity 4)
RHP Report 3 Future Strategies and Activities 68 RHP Evaluation Report - Conclusions Summary Table of UNICEF Software and Hardware Inputs for each Site
Chuka - uiapclia Lommunil Tongsa Nyimshong Corn in un ii Tsirang —Tsokhana Corn inun ii
Tongsa - Langtei Conirnunii
Tsirang — Shemjong Cornrnui-iii Tsirang —Chanauti Communi The above table is a collation of the infoniiation from the RHP evaluation site visits.
Only Lam attended training - 2 Monks stay at the Shedra for four years. Those who participated in the gewog training have left. Some new students have received training from Mongar Rabdey
69 RHP Report 3 Future Strategies and Activities RHP Evaluation Report - Conclusions
Software Issues: - -
• - In soiiie sites monks have received training but the trained monks have moved oii • At one site visited the trained monks interviewed had received their training at their previoUs iiistitution • Tile proportion of monks trained in each site varies eg. only tile Lam has received training in one site whereas according to the record 90 out of 120 monks were trained in
- Moi~arRabdey - • Iii the. Shedras monks llave received training but they are engaged in studies and have little direct contact with the local conln~un.ityfor pujas, etc.
Hardware Issues: • Some sites have received ilardware, which for various reasons is no longer functioning
• - Some sites have received hardware from several sources incltidiiig UNICEF and are not sui’e who funded what, for example inthe case where the Lam Neten is newly appointed
-- to the Rabdey or where the funding was channelled through the Dzongkhag.
- Severai iiistitutioils, which are clearly i-n need of improved hardware facilities, are on hold because of major renovations or piaiined move to another iocatioii, • One site had poor water facilities due to the expansion of other institutions such as schools arid BHU services, and tile growth of the local population. • in Tongsa and Bunithang the monks move between two sites from winter to summer and the number of users of the facilities changes from 30 to 330 for each site. • In Punakha the nui-nber of resident monks can range between 100 in summer to 1000 for
a major puja. -
RHP Report 3 Future Strategies and Activities 70 RHP Evaluation Report - Conclusions
Strategy 3. Training Review the Present Training Programmes and Modify as necessary
Baseline data is required, as in Strategy 2a and 2b. above, ~hich describes the software that has already been provided by UNICEF. At present this information is la~geiyin the institutional memory of 2-3 people. Data should be collated covering participants,
facilitators, content, location and - date ------ii. A full list of all potential participants is also required, by religious institution and religious community, to be able to identify future priorities and target groups. iii. A Needs Analysis is required to identify the Ileeds of participants and the needs of the community. This will vary from workshop to workshop, and from district to district.
iv. Plan each workshop taking into consideration: - • Who will facilitate: suggestions arising from evaluation:- the facilitators could be trained trainers, monks facilitating within tile Dzongkhag and between Dzongkhags, the health workers with influential people to monitor and supervise, or focal persons from both religion and health sectors. • What topics should be covered: suggestions arising from the evaluation are given in Key Question e3. The messages should be simple and refreshercourses should be given. The reiigious practitioners’ role as health promoter should be clarified in the
training. - - - - - • Who will participate: Selection criteria need to be defined. Suggestions arising
-- - from the evaluation:------
• Train educated and influential religious pra~1itioners. They can then run aworksliop in their village and can then reach everyone. Local people will not listen to an outsider. • Train the religious practitioners- who ci,’e capable and interested in communicating health messages and those who work regularly in the community.
• Train those religious practitioners who June no! bethi trained and who may continue to - conduct the puja and delay the medical -treatment. -
• Train those religious- practitioners in lizore remote locatiOns where change is more gradual - or perhaps more resisted, or where access to health services is more difficult
• Use SO~Cselection criteria for participation in workshops for example the trustfrom ~he conznzun,ii’ and the rn/crest of/he religious practitioner inthe training
• I-IA wanted to train af,vara ancigoinciwn he/ore 77vechu but there was no budget • Who will coordinate and manage the training: the evaluation responses suggest coordination between health workers and Dratsang. taken down to the village level to include the VHW and gop, tsokpa or chimi. A regular programme of workshops and
Gu idel ities lbr Facilitators are requested. - - -
71 RHP Report 3 Future StrateL’ies and Activities Rl-IP Evaluation Report - Conclusions Training: Review the Present Training Programmes and Modify as necessary
Activity 1-2: Identification of target groups and priorities i. Compare the baseline data of training already conducted against the full range of potential participants. Identify, from this comparison, areas of weakness in the coverage of RHP training to date. ii. The mallagenlent team should decide on the priority target groups as tile focus for future RI-IP training (linked to Activity 3)’. Is the priority target group: • Religious practitioners at community level? • Institution-based religious communities? • Mixed religious practitioners and influential community members’? • More remote and isolated locations? • Refresher course for those already trained or training for those as yet untrained?
Activity 13: Needs Analysis i. A Needs Analysis for each trainulg workshop Silould be undertaken at two levels: • A simple Needs Analysis by the local health workers to assess tile H+H needs of the community, whicil can then be used to identify tile key topics for tile workshop. • A Needs Analysis of the participants to assess their level of knowledge and main areas of weakness in the H+H topics. This can be done by the facilitators at the beginning of the workshop, through discussion. The facilitators will need to be able to incorporate this assessnlent into the worksllop. They may have to modify the trainillg programme at tile last moment. ii. A survey of attendance at MCI-I clinics could he conducted to identify tile H+H practices of mothers and children, information could he gathered by health workers on:
changing views — mothers to grandparents view • difference between rural and urban practices and views • perceptions and understanding of llealth issues • concerns and prohlenls concerning healtll issues
Activity 14: Workshop Planning i. Plan in advance to give sufficient tulle to: • Identify training needs (Activity 13) and select the topics based on tile Ileeds analysis • Prepare the facilitators • Select the participants based on clear criterion • Organise the logistics and budget at Dzongkhag or village level ii. Ensure. by the end ofthe workshop. that participants understand the difference between serious iihites~esand less serious illnesses and can detect the signs and symptoms of
RHP Report 3 Future Strategies and Activities 72 RHP Evaluation Report - Conclusions
more serious illness. Also that they advise on medical treatment first and then puja in the case of serious illnesses. iii. With advice from Health Division, decide how the topic of STD/AIDS should be presented for religious practitioners. iv. Use a variety of methodologies including participatory activities and visual resources v. Plall tile monitoring compoflellt of tile training (linked to Activity 9iv.) vi. A nlodification of the Health Knowledge Test could be used to assess the health knowledge of participants before and after tile training. The test has to be given orally so could be given to a small, random salllple of participants. Care should he taken not to make tilis threatening or off-putting to the participants since it will he all unfamiliar
- exercise to those who are uneducated. vii. Prepare Guidelines for ‘I’raining Courses
Activity 15: Review RHP Training - Alternative Models i. Tile management team sllould consider the following Models -for RHP Training proposed by religious practitioners and heaitll workers during the evaluation. Several different training models could he piloted and monitored over a 2-3 year period. For example: • Target a gewog whicil has not had illput yet~conduct a baseline sample survey of peoples’ beliefs and practices, access to water and sanitation facilities. COfiliTlOfi problems. etc. Compare with a follow up study after I yr and 2 yrs • ‘I’rain nlonks and community based religious practitioners as facilitators. The introduce a programme of village based trailling using lllOIlkS as facilitators • Irain monks and community-based religious practitioners as VHW. • Training only religious practitioners or training religious practitioners and comnlunity people tile two Optiolls require a different training locus. Do they both align with the RI-IP Pro~ctOhjectives (Activity I ) ii. Plan future training progralllnles based on the outcome of Activity 12 and 1 3. tailoring the participants, topics and coordination of the workshops accordingly.
The strategies and activities described in this section are drawn from suggestions put iorward by religious practitioners and health workers in response to tile evaluation questions.
The Religion and Health Project filallagenlent team can pick Irom these suggestions tile strategies and activities whicil are most workable or are considered most appropriate -for tile future direction of the project.
The over—riding inlpression li’Olll tile evaluation was tile enthusiasnl and interest shown in the project. II’ the managenlent team can told ways to ilarlless and utilise this energy thell tile next phase of tile project should continue the achievenlents and success of tile project so far.
73 RHP Report 3 Future Strategies and Activities RHP Evaluation Report - Conclusions
Summary of Future Strategies and Guideline of Activities
Future Strategies Guideline of Activities Project Man agenient and Partiiersliip
Strategy I: Post-Evaluation Review of the RHP Activity I: Review Project Objectives
Project by Stakeholders - . . - . . - Activity 2: Review Roles and Responsibilities
Activity 3: Define Priority Target Groups
Activity 4: Draw up a Plan of Action
Activity 5: Review opportunities for greater Decentralisation
Activity 6: Facilitate a Network between communicators of l-l+H Messages
Monitoring and Evaluation -
Strategy 2. Introduce a Monitoring and Activity 7: Baseline Data Collection Evaluation Process Activity 8: Tools for on-going monitoring of Software and Hardware
Activity 9: Use of Workshop Reports
Activity 10: Roles and Responsibilities for Monitoring & Evaluation
Activity 11: Planning for Evaluation Training Strategy 3 Review the present Training Activity 12: Identification of target groups and Programmes and modify where priorities neces.~a~y Activity 13: Needs Analysis
Activity 14: Workshop Planning
Activity IS: Review RHP Training - Alternative
- Models
Example I: Stakeholder Participation Analysis Matrix - Who does what?
Example 2: SWOC Analysis (Strengths, Weaknesses. Opportunities. Constraints)
Example 3: Activities and Action — who/when
Exaniple 4: Monitoring Framework for RHP Workshops
RHP Report 3 Future Strategies and Activities 74 RHP Evaluation Report - Conclusions
Example 1: Stakeholder Participation Analysis Matrix - Who does what?
Complete one matrix to show the present areas of participation and, through discussion of the results, plan a new matrix of pai’ticipation to reflect revised roles and responsibilities for the future.
IC,,- ~n ~~.) C v.a
Examples ol aspects of ~ eu ,~ ~ ._ -~~ the project in which ~ ~ ~ ~ ~, diti~rcnistat~ehoIdcrs ~ E -~ ~ ~ ~ E Illaspariicipate— ~ I U ~_ CI) a ~~1) ri~ -~ cC~, ~ ~ - n U P ~ — —•_ x —o — — . hindu) as appropriate ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
Project Planning
Management — - central level
Management — district level
Management — village level
Coordination — central level
Coordination — district level
Coordination — village level
local Pout SW planning Selection of Pin-tic pants Selection of location Workshop rnp lemeniation I-lW pkinning I-I \V maintenance . SW Monitoring I-lw Moniloring
Betieficiaries — . Iargct groups
Project Evaluation ~‘
Budget J -~ t
75 Rl-lP Report 3 Future Strategies and Activities RHP Evaluation Report - Conclusions
Example 2: SWOC Analysis (Strengths, Weaknesses, Opportunities, Constraints)
To follow up the Participation Matrix analysis a SWOC analysis could be completed to identify: What works~?Why? What doesn ‘1 work? Why?
Consider (a) strengths, weaknesses, opportunities and constraults at three levels: i. Central level SWOC ii. District level SWOC iii. Village level SWOC (b) for tile key roles eg. managenlent, coordination, planning, facilitating, maintenance
Central level District level Village level Strengths Management
Coordination
Planning
Facilitating training
Maintenance Weaknesses Management
Coordination
Planning
Facilitating training
Mainteii ance Opportunities Management
Coordination
Planning
Facilitating training
Maintenance Constraints
Management -
Coordination
Planning
Facilitating training
Maintenance
RHP Report 3 Future Strategies and Activities 76 RHP Evaluation Report - Conclusions
Example 3: Activities and Action — who/when
Future Strategies and Activities: Suggestions for Project Improvement STRATEGIES/ACTIVITIES BY WHOM/WHEN Strategy 1: Post-Evaluation Review of the RHP Project by Stakeholders
Activity I: Review Project Objectives
Activity 2: Review Roles and Responsibilities
Activity 3: Define Priority Target Groups
Activity 4: Draw up a Plan of Action
Activity 5: Review opportunities for greater Decentralisation
Activity 6: Facilitate a Network between communicators of H+H Messages
Strategy 2. Introduce a Monitoring and Evaluation Process
Activity 7: Baseline Data Collection
Activity 8: Tools for on-going monitoring of Software and 1-lardware
Activity 9: Use of Workshop Reports
Activity 10: Roles and Responsibilities for Monitoring & Evaluation
Activity II: Planning for Evaluation
Training Strategy 3. Review the present 3 raining Programmes and modify where ii ecessary
Activity 12: Identification of target groups and priorities
Activity 13: Needs Analysis
Activity 14: Workshop Planning
Activity IS: Review RHP Training - Alternative Models
Example 1: Stakeholder Participation Analysis Matrix - Who does what?
Exaniple 2: SWOC Analysis (Strengths. Weaknesses. opportunities. Constraints) .
Example 3: Activities and Action — who/when
Example 4: Monitoring Framework for RHP Workshops
77 RHP Re~ort3 Future Strategies and Activities RHP Evaluation Report - Conclusions
Example 4: Monitoring Framework for RHP Workshops
Before any reporting back format is used the following questions should be clarified:
Who is it for? -- Who conlpletes it? How will the information be used? What information do we need to know? Eg. Knowledge before / after RHP How knowledge is received / used Impact on communities
Facilitators could use a sinlple fornlat to report back on workshops:
Location: - Date: Number of participants:
List of participants: - - - - -
List of key facilitators: - -
Key topics covered: -
Budget: -
Participants’ feedback:
Notes- comments:
RHP Report 3 Future Strategies and Activities 78 RHP Evaluation Report - Conclusions
Glossary
Anim Nun ANM Auxiliary Nurse Midwife ARI Acute Respiratory Infection Atsara Bhutanese clown BI-IU Basic Health Unit BHW - Bask Health Worker -, -- Chaupory Village elder (Nepali term) Chimi People’s Representative in the National Assembly Choep Religious practitioner in the village
Dasho Dzongda Head of the District - - - DHSO District Healtil Supervisor Officer
DM0 District Medical Officer - Dratsang Lhentsog Co~incilfor Religious Affairs Druhdra Meditation centre
Dungchen Secretary - - -
Dzong Fortress — residence of the Dratsang and District Administration Dzongkha Bhutan’s national language Dzongner One who takes care of the Dzong FFL Facts for Life (UNICEF publication) Gelong Monk Gewog Block - (ionlchen Community person who practices religion Gomdey lllstitute for training of Gomchen Gotllpa Buddhist temple (liup Village headman I-lealth Assistant ‘cii-’ Health in our Hands (UNICEF publication) I EC I-I Information, Educatioll, Communication for Health Jakri Hindu community religious practitioller Je Khenpo I-lead of tile monastic body in Bllutan
Ki du Consideration — gift Kudung One who looks after discipline in the Dzong Kueney One who takes care of the Lhakang (monastery) Kuensei Bilutan’ s national weekly newspaper Lanl Neten Head Abbot of Rabdey l~hahsa1lgpuja Purification puja Lopen (iengop Assistant prayer leader Mangup Village Conlnlittee Head MCI-I Mother and Child Health clinic Menchey Rinldu Medicinal treatment and puja performed side by side in sickness Merchen One who takes care of the dead body of Lamas OR C Out Reach Clinic Pain Female oracle in Buddhist conlmunity Paildit/Purit Scholar of Hindu religion Powa Male oracle in Buddhist community
- Rabdey District head institution of the monk body RGoB Royal Government of Bhutan
79 RHP Report 3 Future Strategies and Activities RI-IP Evaluation Report - Conclusions
RI-IP Religion and Health Project Rimpoche Reincarnate Lama RWSS Rural Water Supply and Sanitation Sang Herbs for burning Shedra Monastic senior college Sherub Wisdom Thub Method Tsechu Festival (mask dance) on 0~hday of 10th motlth of Bhutanese calendar Tsedup Blessing for long life Tsip Astrologer Tsokpa Village leader Umzey One who leads the puja UNFPA United Nations Populatioll Fund
VHW Village Health Worker -
Mochi tabna doenchi thoen a Bhutanese saying which is spoken by tile oracle - a prediction for future well being will always have some spiritual basis that will require son~eaction to he taken.
RI-IP Report 3 Future Strategies and Activities 80